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CLINICAL    LECTURES 


MENTAL    DISEASES 


BY 

T.  S.  CLOUSTON,  M.D.  Edin.,  F.R.C.P.E., 

PHYSICIAN  SUPERINTENDENT  OF  THE    ROYAL    EDINBURGH  ASYLUM    FOR  THE  INSANE  ;    LECTURER 
ON  MENTAL  DISEASES  IN  THE  EDINBURGH  UNIVERSITY  ;  FORMERLY  CO-EDITOR  "JOURNAL 
OF  MENTAL  SCIENCE  ;"  FOREIGN  ASSOCIATE  OF  THE  S0CI:6tE  MEDICO-PSYCHOLO- 
GIQUE;  honorary  member  of  the  ASSOCIATION  OF  MEDICAL  SUPER- 
INTENDENTS OF  AMERICAN  INSTITUTIONS    FOR   THE    INSANE, 
AND  OF  THE  NEW  ENGLAND  PSYCHOLOGICAL  SOCIETY. 


TO  WHICH  IS  ADDED 


ABSTRACT  OF  THE  STATUTES  OF  THE  UNITED  STATES  AND  OF 

THE  SEVERAL  STATES  AND  TERRITORIES  RELATING 

TO  THE  CUSTODY  OF  THE  INSANE. 


BY 

CHARLES    F.   FOLSOM,   M.D., 

FELLOW  OF  THE  AMERICAN  ACADEMY  OP  ARTS  AND  SCIENCES;    ASSISTANT  PROFESSOR  OF  MENTAL 

DISEASES,  HARVARD  MEDICAL  SCHOOL;    PHYSICIAN    TO  OUT-PATIENTS  WITH 

DISEASES  OF  THE  NERVOUS  SYSTEM,  BOSTON  CITY  HOSPITAL. 


PHILADELPHIA: 

HENRY   C.   LEA'S    SON   &    CO. 
1884. 


Entered  according  to  Act  of  Congress,  in  the  year  1884,  by 

HENRY    C.    LEA'S    SON    &    CO., 

in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


DOKNAN,    PRINTER. 


AMERICAN  PUBLISHER'S  PREFACE. 


The  present  work  has  been  so  favorably  received  in  England 
that  it  is  only  necessary  to  state  that  the  sheets  of  the  American 
edition,  in  their  passage  through  the  press,  have  had  the  super- 
vision of  Dr.  Charles  F.  Folsom,  of  Boston,  To  render  the 
work  complete  as  regards  the  wants  of  the  American  practi- 
tioner, Dr.  Folsom,  with  the  assistance  of  Hollis  K.  Bailey,  Esq., 
has  added  an  appendix  on  the  laws  of  the  United  States,  and  of 
the  several  States,  relating  to  the  custody  of  the  insane.  Prac- 
tice on  this  point  varies  so  much  with  local  statutes  and  deci- 
sions that  an  abstract  of  this  kind  would  seem  to  be  requisite 
as  a  guide  for  the  practitioner  in  the  perplexing  cases  which 
are  liable  to  arise  in  his  practice  at  any  moment.  With  this 
addition  it  is  hoped  that  the  volume  will  be  found  satisfactory 
in  all  essential  points. 

Philadelphia,  April,  1884. 


PREFACE  TO  THE  ENGLISH  EDITION. 


Another  book  on  Mental  Disease  almost  needs  an  apology, 
the  treatises  on  the  subject  of  late  years  having  been  so 
numerous,  and  some  of  them  so  good.  But  the  subject  has 
never  yet,  in  the  opinion  of  many,  been  treated  from  so  en- 
tirely clinical  and  practical  a  point  of  view  as  is  desired  by 
students  of  medicine,  and  by  busy  practitioners.  The  strong 
point  of  a  clinical  lecture  should  be  ^  that  it  appeals  directly 
and  on  all  occasions  to  the  facts  of  disease  as  seen  in  actual 
cases,  following  the  lines  of  the  cases  on  which  it  is  founded. 
It  must  have  its  foundation  in  the  clinical  experience  of  its 
author,  this  giving  it  vividness  and  interest.  Its  weak  points 
are,  that  the  diseases  are  not  treated  in  a  full,  systematic,  and 
generalized  way,  that  the  history  of  investigation  into  them 
cannot  be  entered  into,  and,  therefore,  great  seeming  injustice 
is  done  to  previous  authors  and  investigators.  I  have  been 
much  impressed  in  teaching  students  by  the  fact  that  you  can 
manifestly  interest  every  member  of  a  large  class  when  you 
are  teaching  mental  diseases  clinically,  while  you  fail  to  reach 
some  of  them  by  systematic  descriptions.  Direct  appeals  to 
the  facts  of  nature,  however  fragmentary,  make  more  im- 
pression on  them  than  any  amount  of  elaborate  description. 
These  considerations  led  me  to  publish  the  following  lectures 
as  a  text-book  for  my  students  in  the  University  of  Edin- 
burgh;   and   I  venture   to   indulge   the  hope  that  it  will  also 


VI  PREFACE    TO    THE    ENGLISH    EDITION. 

supply  a  want  vvliich  I  know  many  busy  practitioners  of 
medicine  feel.  The  two  hundred  and  sixty  cases  of  mental 
disease  which  I  describe  and  embody  in  those  lectures  may, 
I  hope,  assist  some  of  my  brethren  in  the  profession  in  their 
treatment  of  a  very  obscure  and  troublesome  class  of  diseases. 
In  the  selection  of  those  cases,  I  had  in  view  rather  their 
applicability  as  good,  ordinary  types  and  guides  than  their 
rarity  or  their  striking  characters.  The  tendency  in  pub- 
lishing mental  cases  has  been  to  fix  on  wonderful  rather  than 
useful  examples. 

I  have  to  acknowledge  with  gratitude  the  assistance  I  have 
received  from  the  present  or  past  staff  of  the  Royal  Edin- 
burgh Asylum,  Drs.  Turnbull,  Carlyle  Johnstone,  Mitchell, 
Spence,  Steedman,  and  Harrison  Thomas,  in  getting  up  the 
statistics  of  many  of  the  forms  of  insanity  from  the  records 
of  the  institution,  and  especially  I  have  to  thank  my  friend. 
Dr.  Ireland,  for  advice  and  help  in  getting  the  work  through 
the  press. 


CONTENTS. 


LECTURE  I. 
THE  CLINICAL  STUDY  OF  MENTAL  DISEASES. 

PAGB 

All  men  students  of  mind — Medical  psychology — Necessity  for  medical  men 
studying  mental  diseases  —  Frequency  of  insanity  —  Specialism — What 
menial  disease  implies — The  standard  of  mental  health  differs — Tempera- 
ments and  diatheses — Body  and  mind — Reproduction  and  its  mental  rela- 
tionships— Clinical  mode  of  studying  mental  symptoms — Nomenclature  of 
mental  diseases — Classification  by  symptoms — Skae's  (clinical)  classification 
— Some  of  the  most  important  anatomical,  physiological,  psj'chological,  and 
pathological  considerations  to  be  kept  in  mind  in  the  clinical  study  of  mental 
diseases — The  method  of  clinically  examining  an  insane  patient,  and  the 
rules  to  be  observed — Home  or  asylum  treatment,        .         .         .         .         .33 

LECTURE  IL 
STATES  OF  MENTAL  DEPRESSION— MELANCHOLIA  {PSVCHALQIA). 

Nearest  mental  health — Seen  at  beginning  of  nearly  all  kinds  of  insanity — 
Physiological  capacity  of  feeling — Physiological  depression — Melancholic 
phases  of  existence  in  all  men — The  melancholic  variety  of  the  nervous 
temperament  and  diathesis — Influence  of  heredity — Crises  of  Life — The 
eight  varieties  of  Melancholia. — Melancholy  and  melancholia  defined. 
Simple  Melancholia. — "  Low  spirits,"  want  of  aftection,  want  of  interest  in 
and  enjoyment  of  life — Fancies,  whims,  with  impairment  of  reasoning 
power — Not  much  body  wasting — Sometimes  goes  no  further — Often  is 
prelude  to  severe  varieties,  or  to  other  forms  of  insanity — Condition  comes 
and  goes,  and  depends  on  slight  causes — Curability — Great  variety  of 
symptoms — Cases  A.  B.  to  A.  J.  Hypochondriacal  Melancholia. — Patient's 
depressed  feelings  centre  round  himself,  and  his  delusions  are  about  his 
bodily  organs  and  functions — Fancies  innumerable  in  kind  and  variety — 
Seldom  very  suicidal — Differences  between  the  sane  and  the  insane  hypo- 
chondriac— The  one  talks  only,  the  other  acts  and  has  lost  his  inhibitory 
power — Relations  of  symptoms  to  peripheral  disease — Cases  from  A.  K.  to 
A.  M.  Delusional  Melancholia. — Delusions  from  beginning  the  most  promi- 
nent symptom — Such  delusions  assigned  by  relatives  as  the  "cause" — 
Visceral  cases — Electrical  and  religious  delusions — List  of  the  delusions  of 
one  hundred  cases — Cases  A.  N.  to  A.  W. — Prognosis  in  worst  class  of 
cases  bad,  as  in  all  "  fixed  delusions,"  ........     68 


vm  CONTENTS. 

LECTUKE  III. 

MELANCHOLIA  {PSYCHALGI A)— continued. 

PAGE 

Excited  {Motor)  Melancholia. — Restlessness,  noise,  agitation,  wringing  hands, 
moaning,  shouting,  tearing  clothes,  violence,  insane  obstinacy — Difficulty 
of  management,  hallucinations — Delirium  Tremens  a  typical  and  exag- 
gerated variety  of  this  state — Muscular  expressions  of  mental  state — Auto- 
matic misery — Cases  A.  V.  to  B.  A. — Trophic  changes,  boils,  irritations  of 
skin  causing  scratchings,  erosions  of  surface,  pulling  out  hair,  etc.  Resistive 
Melancholia. — Difficulty  and  danger  of  this — Masturbation — Cases  B.  B.  to 
B.  E.  Convulsive  Melancholia. — "Whole  of  the  functions  of  convolution 
aifected  in  this — Cases  B.  F.  and  B.  H.  Oi'ganic  Melancholia. — Precedes 
or  accompanies  tumors  or  softenings — Ends  in  dementia — Cases  B.  J.  and 
B.  H.  Suicidal  and  Homicidal  Melancholia. — In  every  case  of  melancholia, 
however  mild,  look  out  for  suicide,  and  guard  against  it.  Meaning  of 
suicidal  feeling — Infinite  variety  of  motive  and  delusion,  and  of  modes  of 
suicide — Concealment — Cunning — Act  depends  much  on  natural  courage 
of  patient,  and  somewhat  on  his  religious  and  moral  principles — Prevalent 
modes  of  suicide  in  individual  cases,  in  nations,  and  in  sexes— Suicide  by 
suggestion,  from  seeing  means  at  hand — Subtlety  and  liability  to  recurrence 
of  the  impulse — Modes  of  forcible  feeding — Frequency — Cases  B.  K.  to  B. 
R. — Inception  of  melancholia — Bodily  symptoms — Causation — Termina- 
tion— Fifty-four  per  cent,  recover — Homicidal  and  suicidal  impulses  and 
acts  frequently  combined — Period  of  life  at  which  most  frequent.  Treat- 
.  ment. — Diet — Tonics,  nutritives,  sedatives,  use  and  abuse — Stimulants  : 
Quinine,  iron,  strychnia,  phosphorus,  the  bromides,  mineral  acids,  laxatives, 
minei-al  waters,  fresh  air,  exercise,  baths,  change  of  air,  scene,  and  associa- 
tion, rest,  occupation,  amusement,  music,  avoidance  of  excitement  or  noise 
or  strain  of  any  kind — Many  attacks  will  "  run  their  course,"  and  "  take 
their  time,"  like  a  fever — Nursing,  watching — Removal  to  an  asylum. 
Prognosis. — Considerations  :  Youth — G^«neral  state  of  body — Fixed  delu- 
sions or  not — Mode  of  onset — Hallucinations — Trophic  symptoms  in  skin — 
Eftect  of  treatment — Convulsions — Suicidal  tendencies — Persistent  refusal 
of  food — Hygiejie  and  prophylaxis  in  children  of  melancholic  and  neurotic 
families — Diet — Mode  of  life  and  learning — Schools — Occupations  and  pro- 
fessions— Sleep — Cramming  and  competitive  examinations,         .         .        .90 

LECTURE  IV. 

STATES  OF  MENTAL  EXALTATION— MANIA  {PSYCHLAMPSIA). 

Physiological  exaltation — Sanguine  variety  of  nervous  temperament — "  Excita- 
bility" of  disposition — Mental  exaltation  physiological  in  childhood — 
Delirious  exaltation  easily  excited  by  increased  temperature  in  childhood — 
Exaltation  and  delirium  occur  at  beginning  and  acme  of  febrile  disorders 
— Depression  at  end  and  afterwards — Sane  v.  Insane  exaltation — Exaltation 
of  functions  follows  increased  circulation,  oxygenation,  and  heat  in  brain — 
Mania  defined  objectively,  melancholia  subjectively — Six  varieties.  Simple 
Mania. — Coherent  elevation — Varieties — Cases  C.  A.  to  C.  J.  Acute  Mania. 
— Only   forms   eight  per  cent. — Premonitory  symptoms.     First  Stage. — 


CONTENTS.  IX 

PAGE 

Sleeplessness — Unsettledness — Talkativeness — Constant  muscular  action — 
Changeability — Irritability — Diminished  self-control — Extravagance — Loss 
of  the  sense  of  the  pi'oprieties,  fitnesses,  and  conventional  moralities —  ^ 
Change  in  the  natural  affections  and  habits — "Common  sense"  gone 
— Increase  in  imaginative  power  and  amount  of  mentalization — "Whole 
man"  different — Loss  of  body  weight — Denial  that  anything  is  wrong. 
Second  Stage. — Total  loss  of  self-control — Incoherence — Violence — Destruc- 
tiveness — Filthy  habits — Taste,  smell,  and  common  sensibility  perverted — 
Shouting — Roaring — Facial  expression  totally  altered — Rapid  loss  of  weight, 
and  exhaustion  of  strength — Tongue  and  mouth  dry — Secretions  altered, 
and  menstruation  stopped.  The  association  of  ideas  in  incoherence — Pre- 
sentation and  representation.  Differential  Diagnosis. — From  alcohol — 
Poisons — "  Suppressed  "  and  "  masked  "  fevers  and  inflammations — Injuries 
to  head — Excited  melancholia — A  case  with  a  new  pathology.  Treatment. 
— Food — Stimulants — Open  air — Sedatives — Skilled  attendance — General 
management — Safety — Anything  that  impairs  appetite  or  digestion  bad — 
Cases  C.  L.  to  C.  Q.  A.  Delusional  Mania. — Delusion  the  essential  element, 
usually  fixed,  with  excitement — Case  of  C.  Q.  B.  Prognosis. — Not  good 
— Greatly  depends  on  fixity  and  intensity  of  delusion.  Chi-onic  Mania. — 
Acute  Mania  continued  in  a  modified  way  for  over  a  year,  with  usually  the 
elements  of  dementia — Cases  C.  Y.  to  C.  Y.  A.  Treatment. — A  lunatic 
asylum.  Prognosis. — Bad.  Ephemeral  Mania. — Four  forms — Case  of 
C.  Z.  Homicidal  Mania. — Cases  of  Willie  Smith  and  C.  T.  Prevalence 
of  Mania. — Fifty-five  per  cent. — Delusions  in  mania — Prognosis — Termi- 
nation— Fifty-four  per  cent,  recover — Thirty  per  cent,  become  demented — 
Five  per  cent,  die — Prophylaxis, 123 


LECTURE  V. 

STATES  OF  ALTERNATION,  PERIODICITY,  AND  RELAPSE  IN 
MENTAL  DISEASES  {FOLIE  CIRCULAIRE,  PSVCHORHVTHM, 
FOLIE  A  DOUBLE  FORME,  CIRCULAR  INSANITY,  PERIODIC 
INSANITY,  RECURRENT  MANIA,  KATATONIA). 

Physiological  alternations  and  periodicity — The  law  of  "  action  and  reaction  " 
— Reproductive  and  sexual  periodicity,  with  their  mental  changes,  eleva- 
tions, perversions,  irritabilities — The  periodicity  of  neuralgia,  epilepsy, 
sleeplessness,  etc. — Folie  Girculaire  a  distinct  disease — First  described  by 
Falret  and  Baillarger — Three  conditions  in  the  circuit :  depression,  exalta- 
tion, and  sanity — Duration  of  these  varj'  in  diflerent  cases — A  very  incurable 
disease — Psychological  interest  of  this  disease — The  same  brain  in  different 
states — Bodily  symptoms  periodic  too,  e.g.,  cephalalgia,  vomiting,  etc. — A 
few  relapses  in  mania  or  melancholia  do  not  constitute  this  disease — Fre- 
quency— Commencement  and  termination.  Treatment.  —  Complete  the 
cure  of  all  insanity  in  youth  and  adolescent  insanity — Prevent  a  "brain 
habit"  being  formed,  or  a  "  vicious  circle  "  being  got  into — The  bromides — 
Non-stimulating  diet — Marriage,  exercise,  regimen — Heredity  the  strongest 
predisposing  cause.     Pathology. — Cases  D.  A.  to  D.  G.,       .         .         .         .170 


CONTENTS. 


LECTURE  VI. 

STATES  OF  FIXED  AND  LIMITED  DELUSION— MONOMANIA 
{MONOPSYCHO  -IS). 

PAGE 

"Delusion,"  popular  and  medical  use  of — Delusion  from  want  of  judgment  in 
idiots  and  imbeciles — Delusions  from  ignorance  and  superstition — False 
sense-impressions  transmitted  to  brain — Sleep  and  dreaming  and  nightmare 
— Definition  of  "  Insane  Delusion  " — Fixity  or  not  of  delusion  important — 
No  pure  monomania.  Types  most  common. — ^Monom-ajiia  of  Grayideur  or 
Pride. — Different  forms — Has  a  basis  in  normal  brain  condition — Day 
dreams,  etc. — Cases  D.  L.  to  D.  O.  D.  Monomania  of  Unseen  Agency. — 
Connection  of  delusions  with  bodily  feelings  and  diseases — Nocturnal 
aggravations — Cases  D.  O.  V.  to  D.  T.  Monomania  of  Suspicion. — Fre- 
quency of  morbid  suspicions  in  insanity — Insane  jealousy — Fear — Con- 
cealment of  delusions — Cases  D.  T.  A.  to  D.  T.  H. — Proportion  of  cases — 
Diagnosis — Infinite  variety  of  delusions  and  subjects  of  delusion.  Mono- 
mania usually  incurable.  How  it  arises :  1.  Out  of  temperament  and 
disposition  ;  2.  After  acute  mania  ;  3.  From  brain  poisoning  by  alcohol,  or 
after  traumatic  injury  ;  4.  From  perverted  sensations — Legal  importance  of 
delusion — Importance  for  diagnosis  and  signing  certificates  of  insanity — 
"Harmless"  and  "  dangerous"  delusions.  Treatment. — Change — Distract 
mind  by  new  ideas,  new  pleasures,  new  work — Correction  of  any  bodily 
disorder,  or  any  cause  of  irritation — Electricity — An  asylum.  Prevention. — 
Counteract  temperament  and  morbid  disposition  by  reason  and  good  princi- 
ples and  habits—  Suitable  choice  of  occupation — Temperance  in  all  things — 
Cheerful  family  life — Work  body  rather  than  brain, 188 


LECTURE  VII. 

STATES  OF  MENTAL  ENFEEBLEMENT  {DEMENTIA,  AMENTIA, 
PSYCHOPARESIS,  CONGENITAL  IMBECILITY,  IDIOCY). 

Physiological  weakness  of  mind — Childhood  and  dotage — Weakness  of  mind 
in  ordinary  bodily  diseases  from  starvation,  exhaustion,  extreme  mental 
effort  and  tension,  or  emotional  shocks — Definition  of  true  dementia — 
Symptoms  negative — Enfeeblement  general,  but  not  uniform,  of  all  the 
faculties  and  mental  powers  —  Originating  mental  power  first  and  most 
markedly  affected — No  line  of  demarcation  between  sane  and  insane  weak- 
ness of  mind — A  typical  case  of  dementia.  E.  A. — Five  varieties,  (a) 
Secondary  [Ordinary)  Dementia. — The  most  common,  important,  and  char- 
acteristic dementia  of  all — The  natural  termination  of  all  insanities,  if 
recovery  or  death  does  not  occur — Acute  insanities  tend  most  towards  it, 
especially  acutely  maniacal  states — Dementia  pathologically  considered  an 
exhausted  trophic  and  functional  state  in  a  delicate  organ  originally  un- 
stable, from  morbid  over-action  —  A  typical  case  —  Clinical  features  — 
Heredity — Acute  mania — Non-recovery — Changes  in  expression  of  face,  of 
tastes,  habits,  volition,  judgment — Affective  nature  —  Memory — Silliness 
— A  mental  death  before  the  rest  of  the  bodj'  dies — Keeducation  of  brain — 
Limits — Bodily  health  often  good — Long  life.  Things  tending  to  Danentia. 
— 1.  Long  duration  of  attack ;    2.  Acuteness ;   3.  Many  previous  attacks ; 


CONTENTS.  XI 


4.  Heredity  very  strong;  5.  Old  age — Milder  forms  of  mental  weakness, 
mental  "twists,"  and  changes,  often  follow  attacks  of  insanity  and  apparent 
recovery — Temporary  states  of  dementia  that  are  recovered  from  after  acute 
attacks  of  mania — Case  of  E.  B.  (6)  Primary  Dementia. — Imbecility  and 
idiocy  defined  —  Classification  of  idiocy,  genetous,  eclampsic,  epileptic, 
paralytic,  inflammatory,  traumatic,  microcephalic,  hydrocephalic,  by  de- 
privation, cretinism — Cases  E.  C.  to  E.  I.  (c)  Senile  Dementia — Kinship 
of  this  to  secondary  dementia.  Special  Characteristics. — Irritability — Loss 
of  memory,  [d)  Organic  Dementia. — Kesults  from  softenings,  apoplexies, 
tumors,  and  such  gross  brain  lesions,     (e)  Alcoholic  Dementia,  .         .         .  204 


LECTURE  VIII. 

STATES  OF  MENTAL  STUPOR  {PSYCHOCOMA). 

A  distinct  variety  of  mental  disease.  Definition. — Lethargy — Stupor — Impres- 
sions on  senses  produce  no  effect — Attention  gone— Desire  and  emotion 
absent — Stupor  from  the  physiological  point  of  view — Connection  with 
reproductive  instinct — Receptivity  and  irritability  of  brain  gone — Higher 
reflex  functions  suspended — Even  reflex  functions  of  cord  lessened — Hunger 
and  thii-st  not  felt — Condition  of  muscles.  Melancholic  Stupor  [Melancholia 
Atonita). — An  intense  melancholia  with  delusions  that  "  paralyze  "  the 
mind — Memory  not  gone — Sensibility  not  gone — Prognosis — Cases  F.  M. 
to  F.  T.  Anergic  Stupor  ("Acute  Dementia"). — A  real  stupor — Sensi- 
bility, memory,  attention,  resistance  gone — Feeble  circulation — Vaso-motor 
paralysis.  Treatment.  —  Vaso-motor  stimulants  —  Continued  current  — 
Strychnine — Iron — Ergot — Warmth — Rubbing.  Moral  treatment  unavail- 
ing— Causation — Prognosis — Cases  F.  P.  to  F.  S.  Secondary  Stupor. — 
Transitory — Sequential,  usually  following  sharp  attacks  of  acute  mania — 
Curable.  General  Paralytic  and  Epileptic  Stupor. — Causation  of  Slupor — 
Prognosis — Treatment, 217 


LECTURE  IX. 

STATES  OF  DEFECTIVE  MENTAL  INHIBITION  {IMPULSIVE  IN- 
SANITY, VOLITIONAL  INSANITY,  UNCONTROLLABLE  IM- 
PULSE, PSYCHOKINESIA,  HYPERKINESIA,  INHIBITORY 
INSANITY,  INSANITY  WITHOUT  DELUSION,  EXALTATION, 
OR  ENFEEBLEMENT,  AFFECTIVE  INSANITY)— TRE  IN- 
SANE DIATHESIS. 

Self-control  in  the  popular  sense — Sane  self-control  need  jiot  be  perfect — Varia- 
tion in  amount  of  in  different  persons,  ages,  and  conditions  of  society — 
Laws,  natural  and  human,  should  teach  it — Physiological  view  of  inhibi- 
tion in  a  child — Its  absence  at  fli-st — Its  gradual  growth  with  brain  devel- 
opment— Degrees  of  inhibition  and  of  accountabilitj' — Conscience  as  a 
physiological  brain  qualitj' — Children  of  criminals  and  of  the  insane — 
Organic  lawlessness — Self-control  affected  in  all  insanities — Want  of  inhib- 
itory power  and  morbid  impulse  as  an  insanity,  without  other  morbid 
mental  sj'mptoms — Uncontrollable  motor  impulses — Coughing — Sudden 
acts  of  defence  and  oftence — Exhaustion  lessens  controlling  power — Meaning 


Xii  CONTENTS. 

PAGE 

of  irritability — Doctrine  of  inhibitory  centres  of  motion,  nutrition,  and 
mental  action — Laycock  s  doctrine  of  reflex  function  of  brain — Illustrated 
by  maternal  instinct  in  cats — Illustrations  and  cases  of  impulsive  but 
reasoning  insanity — Epileptiform  character  in  some  cases — Hereditary  con- 
nection wilh  epilepsy — Impulsive  acts  by  suggestion — Brain  acting  auto- 
matically, just  as  muscles  do  during  sleep  in  coughing,  speaking,  etc. — 
Action  from  impulse  either  by  loss  of  controlling  power,  or  by  an  excessive 
production  of  energy  that  must  find  an  outlet  somewhere — Conscious  and 
unconscious  impulsive  action — Medico-legal  importance  and  difficulty  of 
uncontrollable  action  from  impulse — Defective  inhibition  may  affect  every 
kind  of  action,  every  kind  of  affective  state,  and  every  propensity  and 
instinct — Degree  of  strength — May  result  in  no  action,  but  merely  a  desire 
to  act.  Etiology. — Heredity — Sunstroke — Effects  of  alcohol  on  brain  and 
offspring — Injuries  to  brain — Congenital  defects — Want  of  or  bad  early 
training — "Moral  Idiocy" — "Instinctive  Juvenile  Mania" — Visceral  de- 
rangement and  reflex  irritation — First  symptoms  of  Mania  or  other  insanity. 
Prognosis. — Depends  on  causes — Some  of  the  worst  and  most  hopeless  cases 
of  insanity  as  well  as  most  dangerous  and  troublesome  of  this  class,  and 
some  of  the  slightest.  Treatment. — Protective  to  self  and  others — Change 
of  scene,  and  removal  from  association  of  morbid  ideas — Medical,  by 
improving  health,  strengthening  nervous  tone,  removing  visceral  or  other 
irritation,  the  bromides  and  sedatives — Kegimen,  brain  rest  and  muscular 
exertion,  nutrive  non-stimulating  diet,  no  alcohol — Educative  in  young 
psychokinetics.  Varieties. — (a)  General  Psychokinesia  {Impulsiveness). 
— Cases  E.  L.  and  E.  M.  (6)  Epileptiform  Impulse. — Impulsiveness  the 
mental  characteristic  of  epileptics — "  Mental  explosion  " — Masked  epilepsy. 

(c)  Anhnal  and  Organic  Impulse. — Perverted  sexual  impulses,  taking  forms 
of  impulsive  masturbation,  sodomy,  incest,  rape  on  children,  bestiality — 
Perversion  of  other  appetites,  propensities,  and  instincts,  e.g.,  urine  drink- 
ing, eating  stones,  rags,  nails — Infinite  variety  of  such  impulses — Cases. 

[d)  Homicidal  Impulse. — Medico-legal  importance — Examples — Letter  of 
medical  man  suffering  from  this — Cases  E.  N.  to  E,  N.  B.  (e)  Suicidal 
Impulse. — Conscious  or  unconscious — "With  or  without  depression  of  mind 
— By  suggestion — Instinct  of  love  of  life  perverted — Most  common  of  all 
impulses — Cases  E.  O.  to  E.  P.  (/)  Destructive  Imptdse. — Cases  E.  P.  A. 
and  F.  F.  {g)  Dipsomania. — Importance — Causation — Neurotic  or  drunken 
heredity — Excess  in  drinking — Injuries  to  head — Losses  of  blood — Bad 
hygienic  conditions — Special  functional  conditions — Menstruation,  preg- 
nancy, etc. — Symptoms :  Craving  for  alcohol  and  all  stimulants,  lying, 
general  demoralization,  falling  in  social  scale,  loss  of  all  self-respect,  cring- 
ing, self-indulgence,  irresolution,  loss  of  affection.  Treatment. — Absti- 
nence, isolation,  work,  healthy  food,  regimen,  and  conditions  of  life. 
Prognosis. — Bad  in  niost  cases — Cases  F.  B.  to  F.  D.  [h)  Kleptomania. — 
Rare  in  uncomplicated  form,  but  this  impulse  very  common  in  many  fonns 
of  insanity,  especially  in  general  paralysis,  and  less  so  in  mania  and  con- 
genital imbecility.  ( j)  Pyromania. — Rare  in  uncomplicated  form — Case  of 
F.  E.  (k)  Moral  Insanity. — Congenital  absence  of  sense  cif  right  and 
wrong,  and  incapacity  for  moral  education — We  find  persons  with  no  moral 
sense,  no  remorse,  no  love  of  the  good,  but  a  love  of  and  impulse  to  do 
every  evil  thing — Cases  F.  H.  to  F.  L. — Conscientiousness  hereditary,        .  231 


CONTENTS.  Xlll 


THE  INSANE  DIATHESIS  {NEUROSIS  INSANA). 

PAGE 

Maudsley's  and  Morel's  description — Characterized  by  striking  peculiarities, 
eccentricities,  oddities,  disproportionate  developments,  abnormal  affective- 
nesses,  im practicalness,  impulses,  irregular  action  and  modes  of  life  without 
motives  like  other  men — Connection  with  the  neurosis  and  with  genius — 
Functional  manifestations  of  unstable  nerve  element  in  its  receptive  and 
reaction  aspects — Seen  in  childhood — Importance  of  right  up-bringing  and 
education  of  body  and  mind — Case  of  F.  M., 257 


LECTURE  X. 

GENEEAL  PARALYSIS. 

A  true  disease,  a  pathological  entity — Not  a  mere  group  of  symptoms — Its  im- 
portance and  interest — Definition — Three  stages — A  typical  case  in  first 
stage.  Etiology. — Temperament — All  causes  of  brain  exhaustion  and  irri- 
tation— Excesses  in  drinking — Sexual  excesses — Overwork — Over-anxiety 
— Syphilis — Injuries — Age  at  which  it  occurs  from  twenty-five  to  fifty. 
First  Stage. — Elevation — Increase  of  sense  of  wellbeing — Constant  motion 
— Loss  of  sleep — Exalted  delusions — "Ambitious  delirium" — Facility  — 
Fibrillar  tremblings  of  tongue — Pathognomonic  speech — Slight  incoordi- 
nation of  muscles  of  hands  and  legs  —  Extravagant  conduct — Acutely 
maniacal  state  —  Danger  to  patient's  life  —  Difficulty  of  management  — 
Increase  of  temperature,  especially  in  evening.  Second  Stage.  —  Acute 
excitement  passing  oif — Greater  facility  and  general  silliness  of  mind  — 
Speech,  writing,  and  walking  aflTected — Dilated  pupils — Spurts  of  excite- 
ment— Progression  of  the  paretic  symptoms — Kleptomaniacal  symptoms — 
Surplus  stock  of  motor  energy  easily  exhausted  by  walking — Fragility  of 
bones — Epileptiform  fits  —  "Congestive  attacks."  Third  Stage. — Paresis 
becomes  paralysis — Inability  to  walk  or  speak — Occasional  restlessness — 
Trophic  lesions — Bed-sores — Swallowing  impaired — Tendency  to  choke — 
Relaxation  of  sphincters — Sensibility  deadened — Duration  from  eighteen 
months  to  three  or  four  years — Remarkable  exceptions.  Two  Pathological 
varieties. — 1.  The  cerebral  or  ordinary;  2.  The  tabic  or  eccentric  by  patho- 
logical propagation — The  cerebral  by  far  the  most  numerous.  Symptomato- 
logical  varieties. — 1.  Non-delusional  ;  2.  Epileptiform  ;  3.  Remissional 
where  apparent  recovery  takes  place  for  a  time  ;  4.  Simply  maniacal ;  5. 
The  long-lived ;  6.  The  melancholic.  Chief  Pathological  Appearances. — 
Skull-cap  thickened  and  hardened — Dura  mater  adherent — General  conges- 
tion—Thickening of  pia  mater — Adhesion  of  pia  mater  to  convolutions — 
Atrophy,  general  and  interstitial — Lining  membranes  of  ventricles  granular 
— Hardening  of  tissue — Outer  layer  of  gray  substance  diseased — Prolifera- 
tion of  nuclei — Destruction  of  nerve-cells — Pachymeningitis  hsemorrhagica 
— Essential  mental  feature  is  progressive  enfeeblement  and  facility — What 
is  general  paralysis? — It  is  the  special  and  peculiar  disease  of  the  mind 
tissue — Local  prevalence.  Diseases  with  which  it  may  be  confounded. — 
1.  Alcoholism;  2.  Syphilis  of  brain;  3.  Epilepsy;  4.  Acute  Mania;  5. 
Tumors  of  brain;  6.  Brain  atrophy;  7.  Chorea;  8.  Partial  Aphasia; 
9.  RamoUissement— Cases  from  F.  Y.  to  G.  M., 260 


XIV  CONTENTS. 


PAKALYTIC  INSANITY  (FKOM  GROSS  BRAIN  DISEASE). 

PAGE 

From  apoplexies,  tumoi-s,  atrophies,  chronic  degenerations,  etc. — Symptoms  vary, 
but  always  dementia  —  Analogy  between  paralytic  and  senile  insanity  — 
Motor  symptoms  essential.  Tumors. — Cause :  Irritability — Hallucinations 
— Suspicions — Dementia — Stupor — Speech  affected  like  general  paralysis  in 
some  cases — Congestive  and  epileptiform  attacks — Paralytic  insanity  three 
per  cent,  in  Royal  Edinburgh  Asylum — Statistics — Pathology — Cases  G. 
N.  to  G.  T., .276 


LECTURE  XI. 

EPILEPTIC  INSANITY. 

Very  important — Epilepsy  may  coexist  with  perfect  sanity,  but  it  tends  always 
to  enfeeblement  of  mind — Effects  of  epilepsy  on  development  of  brain  in 
childhood — Stunting — Enfeebling — The  insanity  in  relation  to  the  fits  occurs 
— 1.  After;  2.  Before;  3.  Instead  of  (Masked  Epilepsy) ;  4.  Chronic  de- 
mentia from  continued  epilepsy ;  5.  Epilepsy  ceases  and  mania  takes  its 
place ;  6.  Coming  on  in  chronic  insanity.  Typical  Epileptic  Insanity. — 
Irritability  —  Impulsiveness  —  Want  of  inhibitory  power  —  Tendency  to 
violence — Hallucinations — Homicidal  impulses — Perverted  religious  emo- 
tionalism— Pathology — Prevalence  of  epilepsy  and  epileptic  insanity  in 
different  parts  of  the  country,  and  in  the  two  sexes — Four  per  cent,  here — 
Twenty  per  cent,  in  Cheshire — Pathology.  Treatment. — Precautions  against 
violence  —  An  asylum  —  The  bromides  —  Counter-irritation  —  Results  of 
treatment — Twenty-four  per  cent,  recovered — Local  prevalence — Summary 
of  therapeutical  experiments  as  to  the  effect  of  bromide  of  potassium  — 
Cases  G.  W.  to  H.  O., 286 

TRAUMATIC  INSANITY. 

Definition — Sunstroke  —  Symptoms  —  Motor  symptoms — Two  kinds — Case  of 
traumatic  insanity  cured  by  trephining — Traumatism  acting  as  exciting 
cause  of  ordinary  insanity — Prevalence — Cases  H.  H.  to  H.  M.  A.,   .         .  298 


LECTURE  XII. 

SYPHILITIC  INSANITY. 

Syphilis  of  brain  not  common — Often  no  syphilitic  affections  elsewhere,  and 
few  secondar}-  symptoms — Often  lies  long  dormant — Effect  of  hereditary 
predisposition  to  the  neuroses  in  determining  the  occurrence  of  brain  syph- 
ilis— No  syphilis  of  neurine,  but  of  fibrous  tissues,  neuroglia,  and  blood- 
vessels. Syphilitic  Insanity. — Four  forms:  1.  Secondary — Short  maniacal 
attack  during  secondary  stage;  2.  Delusional  —  Monomania  of  suspicion 
with  hallucinations,  etc.  ;  3.  Vascular  —  That  dependent  on  arteritis  in 
brain — Change  of  character — Irritability — Immorality — Speech  difficulties 
— Dementia — Paralysis  —  Convulsions — Neuroretinitis  ;  4.  Syphilomatous 
— Gumma  or  inflammation  causing  insanity — Convulsions — Intense  ceph- 
alalgia— Fever — Speedy  death  in  some  cases — Symptoms  various  as  the  locus 
in  quo — Partial  paralysis — Afowo-spasms — Neuroses  of  sensibility — Neuro- 


CONTENTS.  XV 

PAGE 

retinitis — Speech  troubles — Mania — Gradual  dementia.  Prognosis.  —  1. 
Form  good ;  2.  Depends  on  stage ;  3.  Bad ;  4.  May  be  good  if  treatment 
early.  Treatment. — That  of  secondary  and  tertiary  syphilis — Value  of 
iodide  of  potassium  in  large  doses  long  continued — Frequency  one-half  per 
cent.— Cases  from  H.  O.  to  H.  Y. 301 

ALCOHOLIC  INSANITY. 

Alcohol  as  a  cause  of  insanity  from  fifteen  to  twenty  per  cent. — As  a  cause  of 
human  degeneration.  Real  Alcoholic  Insanity. — Five  forms  :  1.  Delirium 
Tremens  often  has  a  preliminary  stage  of  suicidal  and  homicidal  impulse — 
Importance  of  this — Often  leaves,  after  many  attacks,  an  insanity  with 
hallucinations  of  hearing  and  morbid  suspicions — Treatment.  2.  Chronic 
Alcoholism. — Motor  symptoms — Suspicions — Hallucinations — Keflex  func- 
tion of  cord  abolished — Likeness  of  speech  to  general  paralysis — Suspicions 
of  poisoning — Tends  to  dementia — First  attacks  curable — Treatment.  3. 
Mauia  a  Potu. — Delirium  ebriosuyn. — Symptoms — Acute  delirious  mania — 
Duration  short — Kind  of  brain  in  which  this  occurs — General  want  of  con- 
trol— Hereditary  predisposition.  4.  Dipsomania.  5.  Alcoholic  degenera- 
tion— The  lowering  eifect  of  alcohol  on  mind — Insanity  from  morphia  and 
chloral— Cases  J.  A.  to  J,  E., 312 

LECTURE  XIII. 

EHEUMATIC  AND  CHOKEIC  INSANITIES. 

Close  connection  between  chorea  and  rheumatism — Cerebro-spinal  rheumatism 
— Eheumatic  insanity — Pain  and  swelling  of  joints  cease — Temperature 
keeps  high  —  Fears — Delirium  —  Hallucinations  —  Tendency  to  injury — 
Sleeplessness — ^Violent  chorea,  followed  by  temporary  paralysis — Symptoms 
probably  result  from  a  metastasis  of  rheumatic  morbid  action  from  joints  to 
cord  and  brain.  Prognosis. — Good.  Treatment. — That  of  rheumatism — 
Delirium  of  chorea  an  incoordinated  mentalization — Chorea  tends  towards 
dementia  in  children — Epidemic  choreic  insanity — Cases  J.  F.  to  J.  A.,     .  319 

GOUTY  OR  PODAGROUS  INSANITY. 

A  rare  disease — Morbid  mental  condition  very  common  in  gout — Sydenham's 
description — "  Goutj'  Mania."  Progiiosis. — Good — Duration  short.  Ter- 
mination.— Recovery  or  congestion  of  brain — Case  of  J.  M.,        .         .         .  325 

PHTHISICAL  INSANITY. 

Mental  effects  of  brain  anaemia — Phthisis  much  more  common  among  the  insane 
than  the  sane.  A  special  connection  between  the  phthisical  and  the  insane 
diathesis,  hereditary  and  otherwise — Frequent  occurrence  of  the  two  diseases 
in  different  members  of  same  family.  Phthisical  Insanity. — Suspicion — 
Slight  mental  weakness — Unsociability — Slight  attacks  of  excitement — 
Monomania  of  suspicion  in  some  cases — Variableness  of  mind — The  phthi- 
sical mind — Anaemic  brain — Nutrition  and  digestion  weak — Danger  of  pre- 
tubercular  stage  of  phthisis — Insanity  begins  first.  Statistics. — 2.7  per 
cent,  of  all  cases  of  insanity.  Ti-eatment. — That  of  phthisis  and  its  dia- 
thesis. Prognosis. — Thirty  per  cent,  recover — Effects  in  phthisis  on  ex- 
isting insanity — Cases  J.  N.  to  J.  P., 326 


XVI  CONTENTS. 

LECTURE  XIV. 

UTERINE,  OR  AMENORRHCEAL  AND  OVARIAN  INSANITY. 

PAGE 

Influence  of  menstruation  on  mind — Of  insanity  on  menstruation — Two  forms : 
melancholic  and  maniacal — Cases  J.  Q.  to  J.  S. — Delusions  of  patients 
often  tinctured  by  diseases  or  disordered  functions  of  ovaries  and  uterus — 
Ovarian  "  Old  Maids'  Insanity  '' — A  baseless  passion  of  an  unprepossessing 
oldmaid— Case  of  J.  T., 336 

HYSTERICAL  INSANITY. 

Insanity  engrafted  on  hysteria — SjTnptoms  of  both  combined — Hystero-epilepsy 
— Laughing — Crying — Incessant  talking — Mock  modestj- — Sexual  and 
erotic  ideas — Imaginary  ailments — Craving  for  notice — Masturbation — 
Dirty  habits.  Treatment. — Tonics — Baths — Occupation — Moral  treatment 
— Discipline — Antispasmodics — Bromides — Attention  to  female  health — 
Non-stimulating  diet — Complications  and  combinations  of  adolescent,  hys- 
terical, and  masturbational  insanities — Letter  of  hysterical  maniac — Occurs 
in  over  two  per  cent,  of  female  cases  of  insanity — Sixty  per  cent,  recover — 
Cases  J.  U.  to  J.  v., 340 

INSANITY  OF  MASTURBATION. 

Habit  of  masturbation  very  common  and  injurious  to  boys  of  neurotic  tempera- 
ment— Masturbation  as  a  symptom  and  complication  of  insanity — Characters 
of  insanity  of  masturbation — Self-feeling — Introspection — Solitary  habits — 
Perverted  emotionalism — Depression — Vacillation — Cowardice — Suicidal 
feelings — Maniacal  attacks — Impulsive  acts  of  violence.  Bodily  signs. — 
Pains  in  back — Pains  in  head — Ringing  in  ears — Palpitation,  etc. — Forms 
2.2  per  cent,  of  all  insanity.  Treatment. — Tonic — Bracing  diet — Regimen 
— Baths  —  Occupation  —  Muscular  exercise  —  No  local  means — Occurs  in 
fifteen  per  cent. — Twenty-five  per  cent,  recover — Cases  J.  AV.  to  K.  A.,     .  342 


LECnJRE  XV. 
PUERPERAL  INSANITY. 

Limited  to  that  occurring  six  weeks  after  childbirth — Importance  of  this  form — 
Five  per  cent,  of  the  insanity  among  women — Occurs  in  one  in  four  hun- 
dred labors.  Symptoms. — Change  of  manner — Inattention — Carelessness 
about  child — Danger  to  child's  life — Incoherence — Mania — Eroticism — 
Feeble  pulse — Weak  bodily  state — Stoppage  of  lochia — Septic  condition  of 
womb — High  temperature — Tenderness  over  womb.  TVeatment. — ^Good 
nursing — Feeding  often — Stimulants  in  large  quantities — Sedatives — 
Asylum  treatment  depends  on  circumstances  of  patient — Counter-irritation 
over  uterus — Antiseptic  wash« — Statistics — Ages — Heredity — Moral  causes 
— Illegitimacy — One  of  the  cases  after  first  labors — Begins  in  fifty  per  cent, 
within  first  week  after  delivery — In  eighty  per  cent,  within  first  fortnight 
— Most  cases  acute — Seventy-five  per  cent,  recovered — 8.3  per  cent,  died — 
Case*  K.  B.  to  K.  G., 349 


CONTENTS.  XVU 


INSANITY  OF  LACTATION. 

PAGS 

An  anjemic  insanity — Occurs  most  commonly  after  prolonged  lactation — Risk 
greatest  after  several  children — Mental  symptoms  melancholia  and  mania — 
Premonitory  symptoms  usually  present — Headaches — Tinnitiut  aurium — 
flashes  of  light — Irritability — Precordial  anxiety — Forms  over  four  per 
cent,  of  insanity  in  females.  Progno»is. — Good — Seventy-seven  and  a  half 
per  cent,  recover.  Treatment. — Stop  nursing — Tonic  and  Supporting — 
Statistics  of  forty  cases — Case  of  K.  J., 359 

INSANITY  OF  PREGNANCY. 

Rare — ^The  psychology  of  pregnancy — Occurs  most  frequently  in  a  mild  form — 
Usually  melancholic — Suicidal  tendency  in  half  the  cases — Connection  of 
the  insanity  with  the  morbid  cravings,  etc.,  of  pregnancy — Few  cases  of 
stupor — A  few  of  dipsomania — Only  a  few  of  the  severe  cases  recover  at 
childbirth — Sixty  per  cent,  recover — Cases  K.  L.  to  K.  O.,  .         .         .  363 


LECTUKE  XVI. 

THE  INSANITIES  OF  THE  TIMES  OF  LIFE. 

Enormous  differences  in  the  physiological  activities  of  the  brain  at  different 
periods — Type  of  mental  derangement  much  influenced  by  the  special 
physiological  activity  or  decadence  of  the  period, 368 

INSANITY  OF  PUBERTY. 

Rare — Only  two  cases  in  Royal  Edinburgh  Asylum  at  ages  of  14  and  15  out  of 
1800  cases,  and  only  twenty-two  at  16  and  17 — Always  hereditary — Acute 
— Remittent — Not  dangerous  to  life — Maniacal — Theories  and  practices  of 
education  at  puberty — Half  the  general  population  are  under  20 — Only  1.5 
per  cent,  of  the  insane  under  20 — 8  per  cent,  of  general  population  over  60 
— 17  per  cent,  of  the  insane.  Prognosis. — Good.  Treatment. — Tonics — 
Fresh  air — Baths — Milk  and  farinaceous  diet — Cod-liver  oil — Bromide  of 
potassium — No  opium  or  chloral — Case  of  K.  P.,         ....  368 

INSANITY  OF  ADOLESCENCE. 

Meaning  of  Adolescence — Physiological  and  psychological  characteristics — 
Momentous  period — Far  more  so  than  puberty — Novelists  the  best  students 
and  describers  of  the  mental  characteristics  of  adolescence — Gwendolen 
Harleth  [Daniel  Deronda) — Relationship  of  adolescence  to  emotion — Sense 
of  duty — Capacity  for  work — Sentiment — Religious  sense — Courtship — En- 
gagements to  marry — Sexual  intercourse — Of  1800  cases  230  uncomplicated 
between  ages  of  14  and  25 — Of  these  49  occurred  at  the  ages  of  18,  19,  and 
20,  while  157  occurred  from  21  to  25.  Mental  Symptoms. — 78  per  cent, 
exaltation — Only  22  per  cent,  depression — Mania,  acute,  remittent,  relap- 
sing in  66  per  cent — Hereditary  predisposition  very  common  (45  per  cent, 
ascertained,  far  more  than  that  in  reality) — Morbid  ideas,  emotions,  speech, 
and  conduct  tinctured  by  erotic,  sexual,  or  adolescent  characteristics.  Prog- 
nosis.— Good — At  least  66  per  cent,  recover — Remainder  mostly  become  de- 
mented and  live  long,  bodily  health  often  bein^  good.     MorUdity  Small. — 

B 


XVm  CONTENTS. 

PAGE 

Only  1.8  per  cent.  died.  Treatment. — Same  as  for  insanity  of  puberty. 
Signs  and  Accompaniments  of  Recovery. — Perfect  development  of  form  and 
mammae — Growth  of  beard  and  sexual  hair — Change  of  voice — Psycho- 
logically and  bodily  they  emerge  from  attack  men  and  women — Case  from 
K.  Q.  to  K.  v., 375 


LFCTURE  XVII. 

CLIMACTEKIC  INSANITY. 

Normal  psychology  and  physiological  characteristics  of  period.  Mental  Symp- 
toms in  Typical  Case. — Loss  of  keen  interest  in  life — Fits  of  depression — 
Capacity  for  work  diminished — Irritability — Suspicion.  Sense  of  Fear 
and  Impending  Danger. — Change  of  connubial  affection — Suicidal  longings 
— Vague  melancholic  delusions.  Bodily  Symptoms. — Sensory  neuroses — 
Vertigo — Pains — Sensations  of  heat — Vaso-motor  neuroses,  flushings,  etc. 
Motor  Symptoms. — Kestlessness — Statistics  of  two  hundred  and  twenty- 
eight  ciises — Ages — Character  subacute  and  melancholic — Fifty-three  per 
cent,  recovered — Duration  of  attack.  Treatment. — Change  of  scene — 
Travel — Change  of  air  and  diet — Iron  and  quinine — Sea-hathing — Fresh 
air — Fattening  diet — The  bromides — Cases  K.  V.  to  K.  Y.,        .         .         .  388 

SENILE  INSANITY. 

Normal  psychology  of  old  age — Senile  insanity — Heredity  low — Variety  of 
mental  symptoms — Automatic  misery  and  suicidal  attempts — Transient 
cases — Short  delirium  before  death — The  dotards — Senile  suspicions — Re- 
fusal of  food — Ages — Thirty-five  per  cent,  recovered — Mortality.  Pa- 
thology.— Relationship  to  atheroma  of  arteries,  shrinking  of  brain,  and  de- 
generation and  atrophy  of  cells  of  convolutions — Apoplexies — Softenings. 
Treatment  and  management. — Nursing — Support — Sedatives — Stimulants 
—Diet— Cases  L.  A.  to  L.  G., 395 


LECTURE  XVIII. 

THE  RARER  AND  LESS  IMPORTANT  CLINICAL  VARIETIES  OF 
MENTAL  DISTURBANCES. 

1.  Anaemic  insanity — 2.  Diabetic  insanity — 3.  The  in^^anity  of  Bright's  disease 
— 4.  The  insanity  of  oxaluria  and  phosphaturia — 5.  The  insanity  of  cyanosis 
from  bronchitis,  asthma,  and  cardiac  disease — 6.  Metastatic  insanity — 7. 
Post-febrile  insanity — 8.  Insanity  from  deprivation  of  the  senses — 9.  The 
mental  disturbance  of  myxoedema — 10.  Insanity  a>sociated  with  exoph- 
thalmic goitre — 11.  The  delirium  and  mental  disturbances  of  young 
children — 12.  The  insanity  of  load-poisoning — 13.  Post-connubial  in- 
sanity— 14.  The  pseudo-insanity  of  somnambulism, 411 


CONTENTS.  XIX 


LECTURE  XIX. 

MEDICO-LEGAL  AND  MEDICO-SOCIAL  DUTIES  OF  MEDICAL  MEN 
IN  RELATION  TO  INSANITY. 

1.  Taking  the  responsibility  of  advising  the  restriction  of  liberty,  and  placing 
cases  under  the  care  of  attendants  at  home.  2.  .Signing  medical  certificates 
of  insanit}',  in  order  to  place  patients  in  asylums  and  under  care  in  private 
houses:  (a)  Is  the  patient  insane?  (b)  If  so,  is  he  "a  proper  person  to  be 
detained  under  care  and  treatment?"  (c)  Why  should  he  be  placed  in  an 
asylum  or  sent  from  home  ?  [d)  Is  there  any  legal  risk  to  those  who  take 
the  steps  for  asylum  treatment  ?  (e)  Fill  up  even  the  formal  part  of  the 
certificate  up  to  "Facts"  carefully;  (/)  "Facts  indicating  insanity  ob- 
served by  myself"  the  most  important  part  of  certificate — Delusions — Ap- 
pearance and  manner  of  patient — Expression  of  face — Incoherence — Want 
of  memory — Change  from  natural  condition — Suicidal  or  homicidal  expres- 
sions— Taciturnity — Quote  words  used — Put  no  redundancies — Cumulate 
facts — Use  facts  observed  at  other  interviews;  (g)  "Facts  communicated 
by  others,"  corroborative — Attempts  at  suicide — Assaults — Paroxysmal 
aggravations;  (h)  Get  the  cue  to  delusions,  etc.,  from  others  before  you 
see  patient ;  (t)  Necessity  for  tact — Sometimes  a  little  stratagem — Cunning 
and  reticence  of  patients ;  (k)  Cannot  keep  patients  in  private  houses  with- 
out certificate  in  England,  or  notice  to  Commissioners  in  Scotland.  3.  Giving 
certificates  of  sanity — Need  for  care  and  caution.  4.  Giving  certificates  as 
to  the  appointment  of  a  curator  bonis  in  Scotland,  and  making  affidavits 
and  giving  evidence  before  a  master  in  lunacy  in  England  and  Ireland 
when  a  commission  de  lunatico  inquirendo  is  held  by  him,  5.  Giving 
evidence  as  to  the  existence  of  mental  disease  or  not  in  criminal  cases,  to 
enable  the  law  to  fix  or  absolve  from  responsibility,  before  higher  and  lower 
courts,  and  as  adviser  to  procurator-fiscal  in  Scotland.  Crimes  most  com- 
monly eomm.itted  in  Mania. — Epileptic,  Alcoholic,  Puerperal,  and  Simple. 
Melancholia. — Delusional.  Dementia. — Impulsive  violence.  Impulsive 
Insanity. — Homicidal,  kleptomania,  pyromania,  animal  impulse — Compli- 
cations of  insanity  with  drunkenness — Somnambulism  and  allied  states — 
Divergence  of  medical  and  legal  views.  Successive  Legal  Views. — Wild 
beast  theory  (Tracey) — Knowledge  of  right  and  wrong  (Mansfield) — 
Knowledge  of  right  and  wrung  as  to  the  act  (Twelve  Judges) — Delusional 
test  (Denman) — Habit  and  repute  (Moncriefi") — Power  of  control  (New 
Criminal  Code,  Stephen) — Difficulty  of  cases  on  the  borderland — Necessity 
for  caution,  full  knowledge  of  all  the  facts,  and  strict  impartiality.  6. 
Will-making. — Is  he  free  from  the  influence  of  drink  or  drugs  ?  Does  he 
understand  the  nature  of  the  act  he  is  doing,  and  the  efl"ect  of  the  document  ? 
Is  the  disposition  of  the  property  a  natural  one  ?  Is  it  not  influenced  by 
insane  delusion  or  insane  state  of  mind  ?  Is  there  no  facility  with  undue 
influence  being  exerted?  Can  he  tell  twice  over  the  disposition  he  wishes 
to  make  ?  Does  he  know  how  much  property  he  has  ?  Do  not  let  a  good 
motive  sanction  a  bad  will.  7.  Detecting  Feigned  Insanity. — No  general 
rule — Are  the  symptoms  those  of  any  known  tj-pe  of  insanity  ?  Is  there 
any  motive?  Watch  the  patient  when  he  thinks  he  is  unobserved — Over- 
does his  part — Power  of  endurance — Sleep — Sensibility — Sudden  shocks, 
electric  battery,  etc. — Hysteria — Effect  of  drugs — Difficulty  of  this  question 
— Imitations  of  aggravated  insanity— Self-accusations  of  really  insane  people. 


XX  CONTENTS. 


8.  Giving  confidential  family  advice  as  to  such  matters  as  engagements  to 
marry,  education,  choice  of  profession,  sudden  changes  of  conduct  and 
morals — Dreadful  effect  of  helping  to  increase  the  neuroses,  the  insanity, 
and  the  idiocy  in  the  world — On  the  other  hand,  Maudsley's  opinion  as  to 
the  genius  that  may  result  from  neurotic  marriages — Special  mode  of  educa- 
tion sometimes  needed  for  neurotic  children,        ......  423 


APPENDIX. 


Abstract  of  the  Statutes  of  the  United  States,  and  of  the  several  States  and 

Territories,  relating  to  the  custody  of  the  insane, 435 


DESCRIPTION  OF  THE  PLATES. 


PLATE  I.     {Frontispiece.) 

Appearance  of  the  vertex  of  one  hemisphere  of  the  brain  in  a  case  of  advanced 
General  Paralysis,  a,  Skull-cap  condensed,  h.  Anterior  third  of  brain,  as 
seen  when  dura  mater  was  first  raised,  showing  thickened  milky  arachnoid 
dotted  over  with  small  white  spots,  with  the  opaque  turbid  compensatory  fluid 
under  it,  and  the  tortuous  dilated  veins,  congested  vessels,  the  convolutions 
showing  dimly  through,  c,  Middle  third  of  brain,  showing  the  appearance  of 
the  convolutions  after  the  pia  mater  has  been  removed.  They  are  congested, 
and  the  outer  layers  of  gray  substance  have  been  torn  away  in  irregular  patches, 
from  the  most  projecting  part  of  man}'  of  the  convolutions  having  adhered  to 
the  pia  mater  and  been  removed  with  it.  The  portions  so  removed  have  left 
ragged,  eroded-looking  spaces  where  the  gray  substance  looks  softened,  while  the 
outer  laj^er  looks  hard  and  opaque  on  its  surface,  d,  Shows  the  pia  mater 
stripped  from  middle  third  of  brain,  hanging  down,  concealing  posterior  lobe 
of  brain,  and  showing  the  appearance  of  its  inner  surface  with  the  portions  of 
the  convolutions  adhering  to  it.  It  is  congested  and  thickened,  so  that,  instead 
of  being  like  the  normal  pia  mater,  a  delicate,  filmy,  transparent  membrane,  it 
is  a  tough,  spongy-looking  texture. 

PLATE  II.     (Page  140.) 

Fac-simile  of  a  letter  written  by  a  maniacal  patient,  showing  incoherence,  rapid 
change  of  ideas,  delusions,  hallucinations  of  sight,  an  insane  association  of 
ideas,  and  an  insane  symbolism. 

PLATE  m.     (Page  156.) 

The  appearance  of  a  section  of  the  anterior  lobe  of  the  brain  in  a  patient  who 
had  died  of  the  exhaustion  of  acute  mania.  It  shows — a,  the  congested  gray 
substance  of  the  convolutions ;  h,  congested  white  substance  near  gray  matter  ; 
c,  an  inner  ring  of  still  more  intense  congestion  along  the  line  of  junction  of  the 
gray  and  white  substances,  and  extending  into  the  white  substance ;  and  d, 
limited  areas  of  congestion  in  the  white  substance.  This  is  a  type  of  the  irregu- 
lar vascularity  seen  in  the  brain  very  commonly  in  insanity,  indicating  probably 
during  life  a  disturbed  vaso-motor  condition,  which  may  be  either  the  proximate 
cause,  or  a  necessary  accompaniment,  or  the  eflfect  of  the  mental  disturbance. 


XXll  DESCRIPTION    OF    THE    PLATES. 


PLATE  IV.     (Page  187.) 

Great  thickening  of  skull-cap  anteriorly,  with  enormous  deposits  of  new  osse- 
ous tissue  in  an  irregular  nodulated  way  on  the  inner  table  of  skull,  in  a  case  of 
alternating  insanity  of  over  twenty  years'  duration.  This  is  an  aggravated 
example  and  type  of  what  is  almost  universal  in  chronic  insanity  with  periods  of 
excitement.  It  is  a  proof  of  the  structural  effects  of  such  repeated  congestions 
of  the  branches  of  the  carotid  artery,  even  in  the  hardest  tissue,  and  may  be 
fairly  considered  to  be  of  the  same  nature  as  the  brain  changes  in  the  same 
cases,  which  are  not  so  evident,  but  are  no  doubt  far  more  important.  The 
atrophy  of  the  anterior  lobes  of  the  brain  that  usually  accompanies  such  bony 
thickenings  and  deposits  probably  helps  the  tendency,  there  being  nothing  but 
dura  mater  and  cerebro- spinal  fluid  immediately  under  such  growths. 


PLATE  V.     (Page  306.) 

A  section  through  the  brain  of  a  man  who  had  labored  under  syphilitic  in- 
sanity (the  third  or  vascular  form),  with  slow  arteritis  affecting  the  vessels  sup- 
plying the  anterior  and  part  of  middle  lobes  of  one  hemisphere.  This  had 
caused  slow  starvation  and  absorption  of  nearly  all  the  white  substance  in  the 
centre  of  those  lobes,  leaving  the  gray  matter  of  the  gjTi  almost  intact,  so  that 
there  was  a  bag  of  fluid  inside  with  the  convolutions  as  its  walls.  The  convo- 
lutions looked  at  from  the  inside  are  quite  defined,  and  look  as  if  the  white 
substance  had  been  carefully  scraped  off  them.  This  illustrates  the  greater 
vascularity,  and  consequent  greater  vitahty,  of  the  gray  matter  as  compared 
with  the  white,  as  well  as  the  different  sources  of  the  chief  blood-supply  of  each. 


PLATE  VI     (Page  165.) 

A  chart  showing  the  relative  prevalence  of  Melancholia  (thin  line).  Mania 
(thick  line),  and  Greneral  Paralj'sis  (dotted  line),  in  the  Royal  Edinburgh 
Asylum,  and  the  ages  at  which  those  three  conditions  are  most  prevalent.  The 
numbers  per  1000  of  the  total  admissions  run  along  the  sides,  and  the  ages 
along  the  top  and  bottom  of  the  chart.  It  is  seen  that  most  cases  of  melan- 
cholia occur  between  35  and  40,  while  the  highest  number  suffering  from  mania 
occurred  between  20  and  25.  The  melancholic  line  keeps  high  all  through  the 
end  of  life.  General  paralysis  is  scarcely  found  at  all  before  25,  reaches  its 
acme  between  -iO  and  45,  and  is  not  found  at  all  after  57.  While  maniacal  con- 
ditions rise  highest  as  adolescence  is  completed,  between  20  and  25,  they  rise 
very  high  again  at  the  period  when  melancholic  conditions  prevail  most,  between 
35  and  40 ;  that  is,  when  the  mental  and  moral  causes  of  insanity  are  most 
prevalent,  when  the  business  troubles,  domestic  worries,  the  afflictions,  and  the 
keen  competitions  of  life  are  most  common  or  most  intensely  felt. 


DESCRIPTION    OF     THE    PLATES,  XXlll 


PLATE  VII.     (Page  83.  j 

Five  microscopic  drawings.  Fig.  I.  Cells  of  semilunar  abdominal  ganglion  of 
a  very  bad  case  of  visceral  melancholia,  in  a  condition  of  atrophy,  degeneration, 
and  pigmentation.  This  patient  had  intense  delusions  that  she  had  no  stomach, 
and  that  her  bowels  were  never  moved.  She  had  no  appetite,  and  she  obsti- 
nately refused  food,  and  died  of  exhaustion,  though  regularly  fed  with  the 
stomach-pump. 

Fig.  2.  A  marked  apoplexy  in  a  convolution,  such  as  seen  frequently  in  a 
lesser  degree  in  acute  mania,  general  paralysis,  syphilitic  insanity,  senile  insanity, 
and  epileptic  insanity  (after  Dr.  J.  J.  Brown). 

Fig.  3.  An  epithelial  granulation,  from  the  floor  of  the  fourth  ventricle  of  a 
case  of  advanced  general  paralj^sis,  showing  the  enormous  proliferation  of  the 
epithelial  cells.  There  is  one  or,  at  the  most,  two  normal  layers  of  delicate 
epithelial  cells  in  this  position  ;  but  as  seen  in  the  section  they  have  increased  a 
thousandfold,  and  have  altered  entirely  in  appearance.  At  the  summit  of  the 
granulation  they  are  round,  at  its  base  flattened,  while  under  it  we  observe  a 
sclerosed  layer  of  nervous  tissue,  with  the  neuroglia  enormously  increased  in 
volume.  ' 

Fig.  4.  The  proliferated  and  much  enlarged  nuclei  of  the  neuroglia,  from  a 
convolution  of  an  acute  case  of  general  paralysis,  who  died  of  epileptiform  con- 
vulsions. Those  nuclei  are  seen  to  follow  the  course  of  the  capillaries  in  some 
places,  sometimes  even  taking  their  place,  the  vascular  tissue  having  disappeared 
altogether. 

Fig.  5.  A  very  interesting  section  of  the  outer  part  of  a  convolution  of  a  case 
of  general  paralysis,  as  seen  under  a  low  power.  The  section  had  been  forgotten 
in  water,  and  had  undergone  partial  maceration,  so  that  the  nerve  cells  and 
fibres  had  disappeared,  leaving  only  at  the  free  surface  of  the  convolution  the 
thickened  pia  mater  full  of  nuclei,  then  under  that  the  condensed  and  altered 
outer  layer  of  gray  substance,  which  is  adherent  to  the  pia  mater  in  general 
paralysis,  with  few  capillaries,  then  under  this  is  seen  the  finer  network  of 
capillary  vessels,  and  deeper  still  the  more  open  network  of  vessels  towards  the 
white  substance.  All  these  vessels  were  seen  under  a  high  power  to  be  con- 
gested, their  coats  thickened  and  covered  with  adventitious  fibrous  substance 
and  proliferated  nuclei.  The  actual  space  left  for  the  nerve  cells  is  much  dimin- 
ished in  such  a  case.  The  gradually  increasing  fineness  of  the  vascular  reticula- 
tion in  the  gray  substance  of  a  brain  convolution  as  we  approach  its  peripheral 
surface,  a  fact  to  which  there  is  little  reference  in  works  on  histology,  is  here 
very  well  seen.  A  section  of  a  normal  convolution  would  not  have  held 
together  at  all  under  this  treatment. 


PLATE  VIII.    (Page  306.) 

Fig.  1.  A  small  artery  in  the  brain,  with  all  its  coats  enormously  thickened, 
separated  from  each  other,  and  its  lumen  almost  obliterated,  as  found  in  cases 
of  syphilitic  insanity,  senile  insanity  and  other  forms  (after  Dr.  J.  J.  Brown). 


XXIV  DESCRIPTION    OF    THE    PLATES. 

Fig.  2.  Starved  brain  cells  in  a  convolution,  supplied  by  sucb  an  arterj'^  as  seen 
in  Fig.  1.  The  cells  are  in  various  stages  of  degeneration  and  atrophy,  their 
walls,  processes,  and  nuclei  having  disappeared  (after  Dr.  J.  J.  Brown). 

Fig.  3.  A  portion  of  starved  and  atrophied  brain  substance,  from  a  convolu- 
tion of  a  case  of  senile  insanity.  The  whole  substance  is  loose,  reticulated,  and 
almost  destitute  of  brain  cells  in  upper  part  of  section,  with  only  the  packing 
tissues  and  vessels  left. 

Fig.  4.  Cells  from  the  brain  convolution  of  a  case  of  senile  dementia,  showing 
their  degeneration,  atrophy,  and  pigmentation.  Their  nuclei  remain,  but  their 
processes  have  fallen  off.  Probably  this  illustrates  a  natural  decay  of  the  cell 
itself  rather  than  a  blood  starvation  as  seen  in  Fig.  2  (after  Major,  West  Biding 
Asylum  Medical  Rej)orts,  p.  170). 

Fig.  5.  Shows  a  new  lesion  of  the  brain  discovered  by  Dr.  J.  J.  Brown,  in  a 
case  of  acute  mania  in  the  Royal  Edinburgh  Asylum,  in  1877.  This  is  a  section 
from  a  convolution,  showing  its  free  surface  at  upper  part  of  section,  from  which 
the  pia  mater  had  been  removed,  and  in  the  part  of  gray  substance  drawn  an 
enormous  deposit  of  a  new  substance,  taking  up  most  of  its  middle  laj'ers.  It 
appeared  in  masses,  in  smaller  nuclei-like  bodies,  and  also  round  the  vessels. 
The  larger  cells  seen  in  the  inner  layers  of  the  gray  substance  were  somewhat 
degenerated  and  atrophied,  their  processes  having  disappeared. 


PLATE     1. 


Robertson.  Del'  0  WaMr«imtSot\b  Litlio  Edmlnr^ 

THE  VERTEX  OF  THE  BRAIN  IN  ADVANCED  GENERAL  PARALYSIS. 


CLINICAL  LECTURES  ON  MENTAL  DISEASES. 


LECTURE    I. 

THE  CLINICAL  STUDY  OF  MENTAL  DISEASES. 

All  classes  of  men  have  generalized  ideas  of  mind  according  to  the 
daily  experience  and  the  practical  necessities  of  life  of  each.  It  is  not 
left  to  the  philosopher,  metaphysician,  and  psychologist  to  study  mind. 
The  jurist,  politician,  priest,  and  sociologist  each  has  his  own  system  of 
mental  philosophy.  Nay,  the  policeman  and  the  house-breaker  have  each 
a  crisp  and  concise  theory,  learned  in  the  schools  of  expei'ience  and 
tradition — not  formulated  it  may  be,  but  still  definite  and  practical. 
The  physician  in  practice  has,  more  than  most  men,  opportunities  of 
seeing  a  -wide  range  of  mental  phenomena.  He  comes  into  intimate 
personal  relationship  with  men  and  women  in  circumstances  where  the 
reasoning  and  feelings,  the  instincts  and  propensities  of  human  nature, 
are  exposed  to  his  view  with  as  little  concealment  or  hypocrisy  as  pos- 
sible. There  are  very  few  of  the  serious  diseases  he  treats  but  affect  the 
minds  of  his  patients  more  or  less  in  some  way.  He  has  to  study  care- 
fully the  effects  of  their  outward  surroundings  and  of  the  impressions 
from  without  on  the  minds  of  his  patients.  He  has  to  calculate  the  effect 
of  his  own  speech  and  conduct,  as  well  as  those  of  all  Avho  surround 
them.  He  has  to  do  with  mind  in  its  most  undeveloped  form  up  through 
all  its  stages  of  growth  and  education,  and  he  has  the  opportunity  of 
seeing  the  effects  on  it  of  every  form  of  disease  and  debility.  In  addition 
to  this  he  is  called  on  to  treat  mental  symptoms  when,  through  their 
striking  abnormality,  they  have  themselves  become  a  disease. 

The  whole  conduct  of  things  in  the  world  is  necessarily  so  based  on 
the  assumption  that  every  man  is  a  responsible  being  with  a  sound  mind,' 
that  any  exception  to  this,  when  it  occurs,  has  a  very  startling  effect. 
In  the  early  ages  it  was  not  admitted  that  such  a  thing  was  possible,  and 
when  a  man's  mind  was  clearly  altered  from  its  normal  state,  and  his 
mental  personality  changed,  they  explained  it  by  the  theory  that  some 
other  personality  had  entered  temporarily  into  the  man,  driven  out  and 
overpowered  the  true  occupant,  and  that  the  man  was  possessed  with  a 
devil,  or  some  spirit  good  or  bad  other  than  his  own.  It  is  certainly  no 
wonder  that  before  the  physiology  of  the  brain  was  studied  such  a  theory 
was  adopted.  The  facts  were  so  inexplicable  on  any  current  hypothesis 
of  mind,  that  they  needed  a  supernatural  cause.  Looked  at  from  the 
human  and  social  point  of  view,  no  other  disease   at   all   approaches 

3 


84  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

mental  disorder  in  the  terror  it  inspires,  the  sense  of  helplessness  it 
causes,  the  deep  distress  to  relatives,  and  the  disturbance  of  all  social 
ties.  It  is  no  wonder  that  its  study  was  backward,  and  its  treatment 
barbarous,  up  till  quite  recent  times.  But  the  modern  scientific  spirit 
could  not,  and  did  not,  allow  this  field  to  lie  fallow,  and  its  study  was 
hardly  begun  when  its  profound  interest  and  great  importance  were  seen. 
It  was  soon  recognized  that  the  mode  of  study  of  this  department  must 
be  precisely  the  same  as  that  required  for  physiology  and  pathology. 
The  physiologist  had  to  study  normal  mind  as  a  form  of  brain  energy ; 
the  physician  had  to  investigate  abnormal  mind  in  the  same  observational 
and  inductive  way  as  he  studied  diseases  of  the  chest.  It  was  very  soon 
apparent  that  the  brain  Avas  the  sole  organ  of  mind,  and  that  the  func- 
tions of  that  organ,  being  multiform,  and  having  relationship  to  every 
part  and  energy  of  the  body,  could  only  be  properly  studied  in  relation 
to  one  another.  It  was  found  impossible  to  place  quite  apart  the  motion 
and  sensation  functions,  the  sleep,  the  animal  appetites  and  instincts,  the 
special  senses,  the  speech,  the  memory,  the  love  of  life,  the  affective, 
the  reasoning,  and  the  controlling  functions.  The  great  problems  thus 
opened  up  have  exercised  a  fascination  over  many  of  the  greatest  men  in 
our  profession  in  modern  times,  men  whose  general  professional  work  did 
not  lie  specially  in  the  treatment  of  mental  disease.  I  need  only  men- 
tion Pinel,  Esquirol,  Feuchtersleben,  Pritchard,  Abercrombie,  Combe, 
Schroeder  van  der  Kolk,  Brodie,  Holland,  Griesinger,  and  Laycock. 
And  as  for  the  pure  psychologists  who  have  lately  studied  mind  from  the 
physiological  point  of  view  their  name  is  legion.  In  this  country  alone, 
Herbert  Spencer,  Darwin,  Huxley,  Lewes,  Maudsley,  Calderwood,  and 
Bain  represent  a  power  of  original  investigation  and  exposition  seldom 
excelled  in  any  one  department  of  science ;  and  this  is  not  wonderful,  for 
if  the  highest  functions  of  the  brain  and  its  derangements  are  not  worthy 
of  study  by  the  best  minds,  what  can  be  supposed  to  be  so  ? 

In  a  strict  sense  the  term  "medical  psychology"  is  a  misnomer;  if 
psychology  is  a  real  science,  it  is  one  and  indivisible,  and  you  might  as 
well  talk  of  medical  mathematics  or  medical  physics  as  medical  psy- 
chology. But  inasmuch  as  medical  men  seldom  have  the  time,  and  only 
a  few  of  them  the  special  aptitude,  for  the  study  of  the  whole  field  of 
psychology,  that  portion  of  it  which  has  a  relation  to  their  physiological 
studies  and  the  practical  work  of  their  profession  has  been  divided  off — 
not,  it  is  true,  by  very  defined  lines — and  called  Medical  Psychology, 
just  as  certain  departments  of  electricity  and  acoustics  may  be  called 
medical  par  excellence.  An  imambitious  definition  of  medical  psy- 
chology might  be  "  Mind — as  it  concerns  Doctors." 

The  necessity  which  exists  for  a  knowledge  of  mental  disease  to  medical 
men  is  best  proved  by  a  few  facts  and  figures.  An  exceptional  power 
has  been  granted  by  law  to  every  member  of  our  profession  in  practice 
of  giving  a  certificate,  the  effect  of  which  is  to  deprive  any  British  sub- 
ject of  his  personal  liberty  on  the  ground  of  insanity.  Surely  such  a 
responsibility  implies  an  obligation  on  our  part  to  know  sometliing  about 
the  subject  of  mental  disease.  How  can  we  know  that  which  we  do  not 
study  ?  And  how  can  the  medical  practitioner  give  advice  and  sign  such 
all-important  certificates  about  a  disease  which,  as  a  medical  student,  he 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  35 

has  never  seen  or  had  explained  to  him  clinically  ?  As  well  might  you 
ask  a  man  to  give  a  life-insurance  certificate  that  a  patient  was  free  from 
heart  disease  who  had  never  listened  to  a  cardiac  murmur.  This  ignor- 
ance is  fraught  with  an  unusual  danger.  While  allowing — nay,  practi- 
cally compelling — us  to  grant  lunacy  certificates,  the  law  punishes  us 
severely  when  they  are  improperly  given,  whether  through  mere  ignor- 
ance or  wrong  intention ;  and  the  common  law  of  the  land  allows  any 
man  who  thinks  he  has  been  aggrieved  or  wronged  by  such  a  certificate 
to  sue  and  punish  the  granter  of  it.  Several  members  of  our  profession 
have  thus  been  brought  into  most  serious  trouble,  professionally  and 
financially,  and  themselves  to  pecuniary  ruin.  The  fact  that,  out  of 
12,176  medical  certificates  of  insanity  in  the  admission  papers  sent  to 
the  office  of  the  Commissioners  in  Lunacy,  2314,  or  one-sixth,  had  to  be 
returned  to  the  writers  for  amendment,  does  not,  I  fear,  tend  to  raise  the 
opinion  of  the  lawyers,  to  whom  those  certificates  are  submitted,  as  to 
either  the  business  power  or  the  knowledge  of  insanity  in  our  profession. 
I  fear  they  are  apt  to  ask — If  the  knowledge  necessary  to  sign  an 
ordinary  lunacy  certificate  is  so  deficient,  what  may  be  expected  in  the 
still  more  important  matter  of  the  knowledge  requisite  for  the  treatment 
of  the  disease  ?  I  have  had  the  500  recent  certificates  sent  to  the  Royal 
Edinburgh  Asylum  gone  over,  and  I  find  that  456  of  them,  or  91  per 
cent.,  omit  a  certain  point,  not  at  all  important  from  a  medical  point  of 
view,  but  so  essential  from  a  legal  point,  that  Sir  Cresswell  Cresswell 
once  decided  that  it  was  a  sine  quel  non  of  a  valid  and  legal  certificate 
according  to  English  law.^  And  it  is  not  as  if  the  signing  of  a  certifi- 
cate  of  lunacy  were  a  matter  of  rarity.  There  were  last  year  over 
90,000  persons  un  ler  certificate  as  being  insane  in  the  United  Kingdom. 
This  number  required  over  100,000  medical  certificates,  or  an  average  of 
at  least  five  certificates  to  each  practising  member  of  our  profession. 
This  takes  no  account  of  the  certificates  of  mental  incompetency  or  com- 
petency that  have  to  be  granted  for  other  reasons  than  placing  a  patient 
under  care.  The  signing  of  such  certificates  is  one  duty,  but  not  the 
most  important,  that  falls  to  medical  men  in  relation  to  mental  disease. 
The  mental  hygiene  of  individuals,  of  families,  and  of  society,  the  early 
recognition  of  mental  symptoms,  their  suitable  treatment,  the  precautions 
that  have  to  be  taken  to  prevent  accidents  and  risk  of  life,  che  solution 
of  the  most  important  question  of  home  or  asylum  treatment,  the  confi- 
dential fiimily  advice  as  to  professions  and  careers  in  life,  and  as  to  the 
formation  of  engagements  and  marriages,  the  grave  decisions  that  have 
to  be  come  to  as  to  questions  of  civil  and  testamentary  capacity  and 
criminal  responsibility — all  or  any  of  these  questions  a  medical  man  may 
have  before  him  at  any  time  after  he  receives  his  medical  qualification. 

When  we  consider  that  one  in  every  300  of  the  population  is  a  regis- 
tered certified  lunatic,  the  marvel  is  how  our  profession  has  hitherto  got 
along  so  well  with  so  little  systematic  teaching  or  clinical  experience  of 

^  The  designation  and  residence,  marked  4  in  the  statutory  form.  The  legal  im- 
portance of  this  part  consists  in  the  fact  that  it  is  the  only  part  of  the  certificate 
where  the  patient  is  fully  identified.  Suppose  "John  Brown"  is  being  certified 
without  his  designation  and  residence,  what  means  is  there  of  legally  distinguishing 
him  from  the  thousands  of  the  same  name  in  the  country? 


36  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

mental  disease.  We  must  remember  that  for  every  person  who  is  ob- 
viously insane  there  is  probably  another  who  has  been  threatened  at  some 
period  of  his  life  with  its  symptoms,  or  labors  under  more  harmless  and 
less  obvious  varieties  of  it.  If  this  vast  mass  of  brain  disease  is  not 
worth  study,  let  the  general  profession  be  freed  from  responsibility  in 
regard  to  it ;  if  this  cannot  be  done,  then,  in  the  name  of  all  that  is 
reasonable,  let  its  study  find  a  place  in  every  medical  curriculum,  as 
urged  by  the  Earl  of  Shaftesbury,  the  veteran  head  of  the  English 
Lunacy  Commission  for  the  past  forty  years,  and  by  almost  all  the 
medical  witnesses  of  repute  who  gave  evidence  before  the  Lunacy  Law 
Committee  of  the  House  of  Commons  of  1877.  But  for  invidious  com- 
parisons, I  think  that  I  could  show  that  there  is  more  than  one  subject 
which  medical  students  have  now  to  study,  and  on  which  they  undergo 
searching  examinations,  that  cannot  compare  in  practical  importance  with 
mental  diseases. 

From  another  point  of  view  the  study  is  important,  for  there  are  now 
more  than  500  medical  appointments  held  in  the  three  kingdoms  in  con- 
nection with  the  treatment  of  mental  diseases,  as  Commissioners  in 
Lunacy,  Lord  Chancellor's  Visitors,  Inspectors  of  Asylums,  Medical 
Superintendents,  Assistant  Medical  Officers,  and  Consulting  Medical 
Officers  to  Asylums.  Most  of  those  appointments  are  held  by  those  who 
never  had  the  opportunity  of  studying  in  any  scientific  or  clinical  way, 
when  students,  the  subjects  of  mental  disease. 

Much  nonsense  is  now-a-days  talked  about  the  relationship  of  the  so- 
called  specialties  in  medicine  to  the  profession  in  general.  On  the  one 
hand,  they  are  referred  to  in  a  mysterious  way,  as  though  they  were 
occult  and  very  sacred  side  chapels  off"  the  temple  of  medicine,  to  enter 
which  special  rites  had  to  be  gone  through ;  and,  on  the  other,  they  are 
spoken  of  as  ugly  excrescences  on  the  noble  form  of  the  building.  They 
are,  in  fact,  simply  the  result  of  the  enormous  increase  of  knowledge, 
which  renders  one  man  or  one  set  of  men  incapable  of  being  equally 
versed  in  the  whole  field.  The  science  of  medicine  has  become  so  wide 
that  we  can  only  cultivate  it  in  parts.  Therefore  we  specialize,  and  must 
specialize  more  and  more.  But,  most  fortunately  for  the  future  unity  of 
our  profession,  its  practical  exigencies  are  such  that  most  of  its  members 
must  know  something  of  all  its  specialties.  The  further  out  the  speci- 
alty is  from  the  main  roads,  the  worse  it  is  for  itself  in  the  long-run. 
It  is  thus  most  difficult  to  avoid  narrowness  and  the  self-complacent  con- 
ceit that  always  goes  with  narrowness.  The  department  of  medicine 
that  has  to  do  with  the  treatment  of  mental  disease  is,  unfortunately  for 
itself,  a  rather  strongly  marked  specialty,  for  when  patients  are  very  ill 
they  must  be  sent  to  hospitals  for  the  insane,  under  the  charge  of  medical 
men  who  make  that  their  business,  and  do  not  usually  practise  much  be- 
yond those  hospitals.  But  then  most  cases  have  to  be  treated  at  home 
for  a  time  at  first  by  the  family  physician,  and  many  cases  do  not  need 
to  be  sent  to  those  hospitals  at  all,  but  can  be  treated  outside  them. 
And  as  time  goes  on,  our  knowledge  of  mental  disease  will  become  more 
generally  diffused  and  more  accurate,  and  such  hospitals  will  be  opened 
as  fields  for  clinical  study,  as  one  department  of  Morningside  Asylum 
has  been  for  many  years  past,  this  having  been  one  of  the  original  inten- 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  3'7 

tions  of  its  founders,  as  stated  in  its  rules.  The  state  of  tilings  to  be 
aimed  at  no  doubt  is,  that  all  medical  men  should  know  something  of  all 
the  specialties,  that  all  specialists  should  be  well  grounded  in  general 
medicine  and  surgery,  and  that  they  should  habitually  mix  with  each 
other  to  widen  their  ideas.  There  is  a  law  of  demand  and  supply  in 
this  matter  as  in  all  others.  If  the  general  public  did  not  put  faith  in 
specialists  for  certain  special  diseases,  it  would  not  consult  them,  and 
they  would  cease  to  exist. 

The  study  and  treatment  of  the  diseases  of  the  mental  functions  of  the 
brain  has  such  close  relations  to  the  study  of  all  other  brain  functions, 
and  to  the  treatment  of  all  other  brain  disorders,  and  the  brain  is  so 
incontestably  the  dominant  organ  of  the  body,  aifecting  all  its  tissues, 
controllino;  all  functions,  regulating  all  its  energies,  that  there  ought  to 
be  less  risk  of  its  study  producing  narrowness,  or  one-sidedness  of  view, 
than  almost  any  other  specialty.  If  mind  is  great,  surely  the  special 
study  of  its  derangements  cannot  be  a  belittling  task.  It  might  well  be 
argued  that  this  study  is  the  highest  branch  of  medicine,  inasmuch  as  it 
is  confessedly  the  most  difficult,  and  relates  to  the  most  important  part  of 
man.  The  existence  of  mental  disease  affects  the  position  and  prospects 
of  those  who  suffer  from  it  more  than  any  other  disease  whatever,  and 
society  and  the  State  take  more  direct  control  of  them  than  any  other 
class  except  the  criminals.  When  any  other  organ  is  affected  by  disease, 
it  is,  after  all,  merely  a  part  of  the  man  that  suffiers ;  when  the  convolu- 
tions of  the  brain  go  w^rong  in  their  mental  functions,  it  is  the  man  him- 
f  self  that  is  affected.  The  rest  of  the  human  organism,  looked  at  teleo- 
Vogically,  subserves  the  brain,  and  all  the  other  functions  of  that  organ 
subserve  the  mental.  Everything  that  lives,  looked  at  from  the  evolu- 
tional point  of  view,  tends  towards  mentalization,  and  all  the  tissues  of 
all  the  nervous  organs  of  all  the  types  of  animal  life  find  their  acme  in 
the  human  brain  convolutions.  From  the  purely  psychological  point  of 
view,  too,  a  study  of  mental  disorders  is  essential  before  the  laws  of  mind 
will  ever  be  properly  understood.  Pathological  change  always  throws 
light  on  physiological  function. 

It  has  always  been  one  of  the  great  hopes  of  those  who  are  interested 
in  the  prevention  of  mental  disease,  that  a  more  thorough  knowledge  of 
its  nature  and  treatment,  and  an  extension  of  the  knowledjie  we  at 
present  possess  among  the  medical  profession,  would  lead  to  a  diminution 
of  its  total  amount.  If  the  brains  that  by  inheritance  had  a  tendency  to 
this  disease  could  be  subjected  during  their  development  and  education  to 
the  right  sort  of  hygienic  and  preventive  influences,  beyond  all  doubt  Ave 
should  have  less  of  the  disease  in  the  world.  If,  during  matured  life, 
those  same  brains  could  be  made  to  avoid  the  exciting  causes  of  the  dis- 
ease, this  would  certainly  still  further  lessen  the  evil.  If  educated 
medical  knowledge  were  brought  to  bear  on  the  customs  of  our  civiliza- 
tion  to  secure  that  they  are  consistent  with  brain  health,  much  might  be 
hoped  for ;  and,  lastly,  if  the  first  signs  that  betoken  danger  to  the  mind 
health  were  observed,  and  the  first  symptoms  of  disease  noticed,  and 
their  true  significance  apprehended,  every  physician  in  practice  knows 
that  their  further  onset  and  progress  could  often  be  arrested.  I  do  not 
say  that  our  knowledge  of  brain  function  in  its  lai'ge  aspect,  and  the 


38  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

influences  that  affect  it  in  the  individual  or  the  family,  are  as  yet  mature 
enough  to  do  all  these  things;  but  how  shall  we  know  if  we  do  not 
study  ?  And  are  not  many  minds  better  than  a  few,  and  more  likely  to 
obtain  fuller  knowledge  of  the  matter?  There  is  a  curious  sort  of  morbid 
delicacy,  too,  in  the  public  mind  about  the  matter,  which  often  prevents 
a  man,  when  he  feels  his  mental  balance  insecure,  from  consulting  his 
f  doctor.  That  abominable  and  cruel  phase  of  public  sentiment,  which  con- 
(  nects  shame  and  disgrace  with  mental  disease,  does  an  immense  amount 
^  of  harm  to  individuals  and  to  society,  and  our  profession  should  by  all ' 
means  fight  against  it.  That  this  prejudice  of  the  Middle  Ages  should 
exist  at  all,  is  the  strongest  proof  of  the  general  ignorance  of  the  matter. 
Except  our  profession  makes  the  study  of  mental  disease  more  general, 
we  shall  never  be  able  fully  to  combat  and  overcome  this  most  injurious 
public  feeling,  because  it  is  only  by  professional  and  scientific  study  that 
we  get  over  the  ideas  of  repulsiveness  to  many  facts  of  nature.  It  was 
only  when  they  were  scientifically  studied  that  surgery  and  midwifery 
overcame  the  ancient  prejudices  against  them. 

The  first  thing  the  physician  in  his  capacity  of  medical  psychologist 
has  to  do,  is  to  form  in  his  own  mind  a  standard  of  health.  And  to  do 
this  he  has  to  go  to  nature.  He  can  no  more  do  it  from  books  than  he 
can  form  a  conception  of  the  healthy  breathing  or  heart  sounds  from 
books.  He  has  to  do  with  man  as  he  exists  in  nature  in  all  the  stages  of 
his  mental  development.  No  ideal  man  as  he  ought  to  be  will  suit  his 
purposes.  If  he  adopted  such  a  standard,  he  would  be  inclined  to  look 
on  very  many  of  the  people  he  met  out  of  sorts  mentally,  and  fit  for 
segregation  from  their  fellows.  He  cannot,  like  the  clergyman,  go  to  his 
Scriptures  or  his  Church  and  find  his  ideal ;  he  cannot  look  on  man  as 
A  Mind  or  A  Soul,  with  a  troublesome  body  attached ;  he  cannot  shut 
the  roads  to  his  senses,  and  construct  out  of  his  subjective  knowledge  the 
man  or  the  mind  that  is  to  be  of  service  to  him  for  comparison ;  he  can- 
not even  look  on  him  as  a  bundle  of  faculties,  feelings,  and  potentialities 
tied  together  with  the  small  cord  of  life.  His  method  of  study  must  be 
the  physiological  method,  assisted,  as  far  as  they  can  be  depended  upon, 
by  his  OAvn  subjective  experiences  and  those  of  his  patients.  How  is  the 
function  of  sensation  studied?  By  accurate  and  scientific  observation  as 
to  the  parts  of  the  body  where  it  is  present,  by  measurements  of  the 
degree  in  which  it  resides  in  different  organs,  by  examination  into  the 
nerves  that  convey  peripheral  impressions  to  the  brain,  how  they  end  in 
the  tissues,  where  they  go  to  in  the  cord  and  in  the  brain.  In  this 
investigation  the  subjective  sensations  of  the  patient  are  essential;  but 
could  we  ever  have  had  any  real  scientific  knowledge  of  the  function  of 
sensation  had  we  trusted  to  this  alone?  Animals  cannot  express  their 
sensations  in  words,  and  yet  where  would  our  knowledge  have  been,  had 
not  Sir  Charles  Bell  been  able,  by  experiment  on  animals  and  otherwise, 
to  demonstrate  that  there  are  distinct  sets  of  nerves  for  sensation  and 
motion?  And  how  incomplete  would  have  been  our  knowledge,  how 
helpless  our  therapeutics,  if  the  function  had  not  been  studied  in  its 
conditions  of  loss,  diminution,  exaltation,  and  alteration  in  disease! 
Just  so  it  is  with  the  function  of  mentalization.  Whatever  our  philo- 
sophical or  religious  beliefs  may  be  in  regard  to  the  Ego  and  the  soul, 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  39 

however  strongly  we  may  feel  ourselves  pressed  oli  the  horns  of  the 
dilemma  that  to  feel  implies  a  personality,  and  that  as  yet  physiology 
has  not  devised  any  hypothesis  by  which  we  can  even  conceive  person- 
ality as  a  brain  function — in  spite  of  this,  we  must,  when  we  come  to 
study  and  treat  patients  whose  mental  functions  are  deranged,  go  on  the 
hypothesis  that  mentalizatiou  is  a  brain  function  as  much  as  sensation  or 
motion. 

The  student  of  mind  from  this  point  of  view  is  met  on  the  very 
threshold  by  the  obvious  fact,  that  it  differs  enormously  in  its  normal 
manifestations  in  different  persons  and  sexes,  in  different  stages  of  life, 
and  in  different  races.  He  sees,  too,  that  it  is  manifestly  influenced  by 
the  other  functions  of  the  organism,  and  the  organs  through  which  those 
functions  are  performed.  These  facts  prepare  him  to  accept  to  some 
degree,  at  least,  the  generalizations  that  previous  students  of  the  subject 
have  made  as  to  the  existence  of  different  mental  types  associated  with 
bodily  characteristics,  or  the  doctrine  of  temperaments  and  diatheses. 
He  sees,  for  example,  that  there  are  certain  persons  in  whom  the  nervous 
functions  are  very  active,  and  seem  specially  to  dominate  the  other  func- 
tions. Such  persons  feel  keenly,  move  quickly,  and  think  clearly,  these 
qualities  being  impressed  on  the  form,  contour,  and  nutrition  of  the 
whole  body.  He  soon  comes  to  observe  that  persons  with  such  a  neurotic 
diathesis  are  liable  to  diseases  special  to  themselves,  and  that  when  they 
suffer  from  ordinary  diseases,  the  neurotic  predominance  in  their  consti- 
tutions often  affects  the  character  and  duration  of  such  diseases.  No 
physician  of  experience  but  knows  that  neuralgias,  hysteria,  paralysis, 
and  convulsions  are  more  common  among  persons  of  this  type  and  their 
children  than  among  the  general  population.  It  is  a  well-known  fact 
that  in  certain  cases  of  this  type,  acute  rheumatism,  for  instance,  will 
attack  the  brain  and  cord,  producing  coma  or  chorea,  and  that  even  the 
syphilitic  poison  will  by  .preference  attack  the  neuroglia  rather  than  the 
joints  in  such  neurotic  constitutions,  and  that  when  such  people  suffer 
from  fevers  they  are  more  apt  to  be  delirious. 

The  facts  of  nature  compel  the  physician  to  see  that  purely  mental 
qualities  and  mental  defects  are  transmissible  from  parent  to  child,  and 
prepare  him  for  the  great  part  that  heredity  plays  in  psychological 
development  and  in  mental  disease.  It  has  not  yet  been  proved  statisti- 
cally whether  the  shape  of  a  man's  nose  or  the  acuteness  of  his  moral 
sense  is  most  apt  to  be  transmitted  to  his  children  or  grandchildren,  but 
I  am  strongly  of  opinion  that  the  latter  will  be  found  to  be  so. 

The  medico-ps3''chological  student  finds  that,  in  addition  to  the  influ- 
ence of  temperament,  diatheses,  and  heredity,  the  working  of  mind  in 
each  individual  is  influenced  daily  by  other  organs  than  the  brain.  He 
finds  the  so-called  animal  and  organic  functions  and  propensities  so  inter- 
woven with  the  purely  mental  functions,  such  intei'action  and  reaction 
between  them  all,  that  he  instinctively  forms  the  conclusion  and  acts  on 
it,  that  he  must  look  on  the  whole  man — body,  mind,  and  spirit — from 
the  point  of  view  of  an  organism  whose  whole  needs  and  capacities 
exhibit  unity  and  solidarity  throughout.  Take,  for  instance,  the  function 
of  alimentation.  No  doubt  the  swallowing,  digestion,  and  absorption  are 
chiefly  mechanical  and  chemical  processes,  performed  in  a  living  labora- 


40  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

tory,  and  take  place  in  the  nerveless  amoeba,  yet  he  would  be  but  a  blind 
and  narrow-sighted  observer  who  foiled  to  see  the  enormous  mental  and 
moral  influence  that  the  desire  for  food,  the  appetite  for  food,  and  the 
varied  pleasures,  organic  and  conscious,  that  suitable  food  produces.  He 
would  soon  in  his  practice  meet  with  cases  where  in  rational  men  a  badly 
cooked  dinner  made  life  not  worth  having  to  themselves,  and  a  torment 
to  those  about  them.  And  a  wider  vicAv  would  show  that  different  kinds 
of  foods  affected  the  mental  development  of  whole  races  of  men  ;  that  the 
desire  to  get  certain  coveted  foods  stimulated  the  highest  ingenuity  and 
thinking  power  of  the  wisest  of  men,  Avhile  the  want  or  poverty  of  food 
had  made  civilized  men  into  wild  beasts,  as  during  the  French  Revolution, 
or  among  shipwrecked  sailors.  The  absolute  dependence  of  the  appetite 
for  food  on  brain  and  ganglionic  integrity  and  sound  working  is  so  often 
seen  by  physicians,  that  they  need  no  physiological  proof  that  the  appe- 
tite is  a  brain  function.  What  stops  the  appetite  at  once  when  sudden 
fear  or  joy  is  felt  ?  Through  what  organ  is  it  perverted  during  pregnancy 
or  in  hysteria  ?  What  stimulates  it  to  ravenousness  in  diabetes,  if  it  is 
not  a  brain  function  ? 

Take  a  function  still  more  nearly  affecting  mentalization,  that  of  the 
reproduction  of  the  species.  AVhat  practical  student  of  mind  can  disre- 
gard it  ?  W^hat  physician  can  overlook  the  part  it  plays  ?  How  directly 
it  influences  the  whole  affective  life  and  history  of  mankind  !  How  the 
ascetic  religionists  of  all  creeds,  with  ideal  a  priori  standards  of  life 
before  them,  have  striven  to  set  themselves  free  from  its  influence  on  their 
minds  and  lives  !  What  attempts  have  been  made  to  degrade  it  into 
something  almost  criminal  and  bruitish  in  one  age,  to  ignore  it  in  the 
next,  and  to  idealize  it  in  the  next !  The  psychological  physician  must 
simply  accept  the  facts  of  physiology,  and  regard  man  as  a  whole,  mind 
and  body.  So  regarding  him,  he  is  every  day  beset  with  problems  that 
imply  consideration  of  the  reproductive  functions  of  the  human  species, 
and  their  effects  direct  and  indirect  on  the  minds  of  liis  patients.  And 
the  sooner  he  begins  to  regard  the  whole  matter  from  the  physiological 
and  professional  point  of  view,  just  as  the  obstetrician  does  his  Avork,  the 
better  for  himself  and  his  patients.  It  will  often  need  all  his  physio- 
logical knowledge  and  his  psychological  study,  combined  with  his  com- 
mon sense  and  general  knowledge  of  human  nature,  to  expiscate  the 
mental  sympathies  and  aversions,  the  reflex  and  sympathetic  irritations 
and  impulses,  and  the  paralyzed  volitions  of  some  of  his  adolescent,  hys- 
terical, puerperal,  celibate,  and  climacteric  patients. 

A  knowledge  of  the  enormous  variety  of  mental  types  seen  in  nature 
will  effectually  prevent  the  physician  from  setting  up  a  Utopian  and  ftilse 
ideal  standard  with  which  to  compare  deranged  mind  when  he  comes  to 
stud}^  that  subject.  It  is  of  the  utmost  practical  importance  that  it  should 
be  so.  Those  students  who  attend  my  clinical  lectures  will  find  that  there 
are  few  questions  I  shall  so  often  ask  as  this — "W'hat  sort  of  man  was 
this  Avhen  he  Avas  reckoned  well  in  mind?"  "How  does  he  noAv  differ 
from  his  state  then?"  "Are  his  present  mental  peculiarities  evolutions 
of  his  temperament?"  "Are  they  connected  with  his  diathesis?" 
"W^hat  is  the  exact  nature  of  the  mental  disturbances  present?"  "Is 
the  judging,  the  feeling,  the  controlling,  the  resistive  powers,  the  memory, 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  41 

or  the  imagination  affected?  and  if  so,  in  what  degrees  and  ways?"  "Is 
there  general  mental  exaltation,  depression,  or  enfeeblement  present?" 
"Are  the  mental  symptoms  fixed  or  changing?"  "Is  the  sleep  function 
interfered  with?"  "Do  those  disturbances  bear  relation  to  any  disturb- 
ance of  the  great  functions  of  the  body  ?"  "What  bodily  functions  are 
disordered  along  with  the  mental?"  "Are  there  any  purely  bodily 
symptoms  present?"  "Was  the  onset  of  the  mental  disease  connected 
with  any  functional  evolution  such  as  puberty,  with  any  ordinary  physio- 
logical process  such  as  menstruation,  or  with  any  extraordinary  physio- 
logical cataclasm  such  as  childbirth?"  "Are  any  of  the  other  great 
functions  of  the  nervous  centres,  such  as  motion  or  sensibility,  impaired? 
and  if  so,  whether  primarily  or  secondarily  to  the  disordered  mentaliza- 
tion?"  This  is  the  clinical  mode  of  studying  mental  disease,  founded 
on  a  physiological  basis.  It  implies  something  far  more  than  merely 
classifying  the  mental  symptoms  of  your  patients,  and  ticketing  the 
various  groups  Avith  a  name.  You  can  easily  imagine  the  same  mental 
symptoms  to  exist,  and,  as  a  matter  of  fact,  they  very  often  do  exist,  in  a 
girl  of  fifteen  entering  on  puberty  and  in  a  puerperal  woman,  but  in  the 
latter  case  the  bodily  symptoms  would  be  quite  different  from  the  former, 
the  temperature  perhaps  being  103°,  the  lochia  absent,  the  tongue  dry, 
the  pulse  feeble,  the  uterus  septic  and  irritated,  and  the  general  condition 
so  weak  that  a  few  more  steps  downward  would  lead  to  death  ;  while  in 
the  former  the  strength  Avould  be  good,  the  pulse  good,  and  the  tempera- 
ture almost  normal.  Both  cases,  looked  at  from  the  point  of  view  of 
mental  symptoms,  would  be  called  acute  mania,  and  yet  they  would  be 
quite  different  in  etiology,  in  bodily  symptoms,  in  prognosis,  and  in 
treatment. 

The  proper  point  from  Avhich  to  start  in  studying  diseased  mentaliza- 
tion  being  the  normal  physiological  energy  of  the  brain,  and  a  recogni- 
tion of  the  fiict  that  the  normal  type  is  not  a  fixed  point  or  line,  but  a 
wide  area  with  far  diverging  promontories  according  to  age,  sex,  race, 
education,  period  of  life,  heredity,  diathesis,  and  temperament,  we  next 
come  to  the  question  of  how  far  mere  temporary  causes,  such  as  changes 
in  the  blood  supply,  excesses  of  Avork,  strains  of  all  kinds,  or  reflex  irrita- 
tions, affect  the  mental  energy  of  the  brain,  but  still  keep  Avithin  a  line 
that  may  be,  and  ought  to  be,  reckoned  physiological.  If  a  man  Avorks 
till  he  cannot  any  longer  lift  his  arm,  we  do  not  call  it  paralysis ;  if  he 
sleeps  so  soundly  afterAvards  that  no  ordinary  stimuli  Avill  aAvake  him,  we 
do  not  call  it  coma :  Ave  place  neither  condition  out  of  the  physiological 
into  the  pathological  state.  So,  if  a  man's  heart  is  made  glad  by  Avine 
or  by  extraordinary  good  news,  and  he  shows  many  signs  of  mental  exal- 
tation unusual  in  him,  or  if  he  loses  blood  or  has  bad  ncAvs,  and  is  pro- 
foundly depressed,  Ave  still  call  those  states  physiological,  and  do  not 
count  them  pathological  mentalization  at  all.  A  man's  poAver  of  judging 
and  comparing,  his  emotional  condition,  his  inhibitory  poAver,  may  all  be 
so  far  paralyzed  as  to  be  in  abeyance  for  the  time,  and  yet  Ave  may  count 
him  perfectly  free  from  mental  disease.  Nay,  I  have  seen  tAvo  men  in 
exactly  the  same  condition  for  the  time  being,  so  far  as  mental  symptoms 
Avere  concerned,  and  I  counted  the  one  sane  and  the  other  insane.  When 
the  limits  of  the  physiological  are  passed,  and  a  man  enters  on  a  patlio- 


42  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

logical  state  of  mind,  we  are  often  utterly  unable  to  tell  the  exact  line 
where  the  one  ends  and  the  other  begins.  As  Maudslcy  says,  you  might 
as  well  attempt  to  draw  the  line  between  light  and  darkness.  There  is  no 
rubicon  over  which  a  man  passes  from  the  one  into  the  other.  Insanity 
does  not  enter  into  a  man  at  one  door,  while  sanity  departs  at  the  other. 
That  fact  you  should  never  forget,  any  more  than  the  fact  (to  take  one 
of  the  most  definite  ascertainable  physical  conditions  of  the  human  body) 
that  you  can  never  tell  where  a  normal  temperature  ends  and  an  abnor- 
mal one  beg-ins.  You  know  that  98°  is  within  the  limits  of  abnormal 
physiological  heat.  You  know  that  108°  is  abnormal  and  pathological, 
but  you  cannot  tell  at  what  point  health  passes  into  disease. 

For  the  study  of  mental  disorders,  while  the  general  state  of  mind  must 
be  the  same  as  that  in  which  we  study  ordinarj^  bodily  diseases,  while  it 
is  essentially  the  clinical  faculties  that  we  put  into  exercise,  yet  there 
needs  to  be  superadded  a  difierent  kind  of  design  and  conscious  eifort  to 
find  out  what  the  morbid  symptoms  are,  more  of  comparison  with  health, 
more  scepticism  as  to  what  the  patient  says  directly  about  his  own  symp- 
toms, and  far  more  strain  in  the  effort  to  draAV  out  the  patient  into  a 
veracious  and  open  state  of  mind.  The  constant  effort  to  interpret 
the  clinical  meanings  of  subtle  changes  in  your  patient's  manner,  and 
the  significance  of  what  he  says  and  how  he  says  it,  is  wearying ;  while 
the  difficulties  of  delicately  leading  him  over  the  ground  where  his  mental 
deficiencies  exist  are  often  excessively  great.  His  every  word  and  act 
must  be  closely  scrutinized,  for  they  form  part  of  the  symptoms  on  which 
your  diagnosis  rests.  An  initial  difiiculty  with  the  uninstructed  is  in  the 
want  of  terms  to  express  the  mental  symptoms.  I  have  heard  a  man 
try  to  describe  the  symptoms  of  an  ordinary  case  of  acute  delirious 
mania  to  me,  and  utterly  fail  to  give  any  connected  idea  of  the  patient's 
state.  Such  a  description  as  this  I  have  often  got :  "  He  won't  do  any- 
thing you  tell  him.  I  can't  make  anything  of  him.  He  talks  a  lot 
of  nonsense.     He's  just  mad." 

Though  our  nomenclature  for  the  deviations  from  normal  mentalization 
is  as  yet  unscientific  and  incomplete,  and  must  one  of  these  days  be 
revised,  yet  most  abnormalities  are  capable  of  being  in  some  way  de- 
scribed or  indicated.  The  common  symptoms  met  with  have  been  classi- 
fied, and  form  the  first  classification  of  mental  diseases  to  which  I  shall 
direct  your  attention.  It  is  in  reality  only  a  classification  of  symptoms, 
not  of  real  diseases,  but  the  symptoms  are  most  important  and  are  the 
first  things  to  be  observed.  The  nomenclature  this  classification  gives  us 
is  quite  essential  for  our  study  of  disordered  mind,  and  its  terms  have 
become  current  in  medicine,  jurisprudence,  and  general  literature. 
Pinel's  and  Esquirol's  original  classification  of  mental  diseases  on  this 
principle  has  undergone  many  modifications  and  extensions,  and  I,  like 
my  predecessors,  have  introduced  some  changes.  The  principles  on 
which  it  is  founded  are,  to  take  one  example,  that  all  the  states  of 
morbid  mental  depression  and  painful  feeling  are  classed  under  one  head, 
Melancholia,  just  as  all  the  painful  disorders  of  sensibility  are  called 
Neuralgia.  Indeed  the  melancholias  bear  a  close  analogy  to  the  neural- 
gias. In  the  one  case  the  mental  functions  of  the  brain  are  affected,  in 
the  other  the  common  sensibility.     Most  cases  of  melancholia  might  be 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  43 

called  mental  pain.     Indeed,  it  would  be  more  scientifically  called  Psy- 
chalgia. 

Then  all  the  states  of  morbid  mental  exaltation  and  excitement  are 
classed  together  and  called  Mania,  just  as  the  motor  storms  and  explo- 
sions are  called  convulsions,  eclampsias,  epilepsies,  or  spasms.  A  typical 
case  of  mania  may  be  considered  like  a  mental  chorea  or  eclampsia. 
There  is  present  disordered,  incoherent,  involuntary,  purposeless  mental- 
ization.  Mania  might  be  called  Psychlampsia,  if  we  wanted  to  set  up  a 
more  uniform  nomenclature  than  we  have  at  present. 

There  are  other  cases  whose  symptoms  consist  of  regularly  alternating 
mental  states,  usually  of  depression  and  exaltation,  this  rhythmical 
recurrence  of  mental  pain  and  spasm  going  on  during  the  whole  course 
of  the  disease,  and  constituting  its  essential  distinctive  character.  I 
think  a  better  name  for  this  than  the  one  given  to  it  by  Baillarger,  who 
first  described  it,  viz..  Folic.  Circulaire,  would  be  Alternating  Insanity. 
Though  only  described  as  a  variety  of  mania  by  him,  yet  I  think  its 
characters  are  so  distinctive  as  to  vindicate  for  it  a  special  place  in  a 
complete  symptomatological  nosology,  which  I  have  accordingly  given  it. 

The  fixed  delusional  states  without  excitement  or  depression  come 
next,  the  Monomanias.  Just  as  we  now  separate  the  monospasms  and 
the  local  convulsions  from  the  general  eclampsias,  I  think  it  is  better  to 
place  the  cases  of  monomania  by  themselves,  instead  of  calling  them,  as 
some  authors  do,  partial  mania.  Monomania  is  analogous  to  a  parses- 
thesia,  being  in  fact  very  often  due  to  a  want  of  correspondence  between 
the  impression  received  by  the  brain  from  the  special  senses  and  the  real 
objective  impressions  that  have  been  made  on  them,  through  their  getting 
distorted  on  their  way  from  the  organs  of  sense  to  the  convolutions.  For 
instance,  if  a  man  hears  distinct  articulate  words  which  are  merely  the 
meanings  of  the  wind  to  others,  and  if  those  subjective  false  voices  call 
him  bad  names,  he  becomes  suspicious  of  the  people  about  him;  this 
becomes  a  morbid  habit  of  his  mind,  without  any  special  excitement  or 
depression,  and  Ave  say  he  labors  under  monomania  of  suspicion.  This 
is  one  way  in  which  delusion  may  arise.  A  true  impression  from  a 
nerve  of  common  sensibility  may  be  misinterpreted,  as  when  a  man  has 
cancer  of  his  stomach  that  causes  him  real  gnawing  pain,  and  he  says  he 
has  rats  inside  him  that  are  eating  his  vitals.  It  might  help  you  to 
understand  this  condition  better  if  it  Avere  called  Monopsychosis. 

When  the  morbid  condition  is  one  of  mental  enfeeblement  it  is  called 
Dementia  or  Amentia,  both  very  good  terms.  The  conditions  they 
represent  are  strictly  analogous  to  the  anaesthesias,  pareses,  and  partial 
paralyses  that  result  when  the  sensory  and  motor  centres  of  the  brain 
are  respectively  diseased.     It  might  be  called  Psychoparesis. 

The  next  on  the  list,  I  have  placed  there  because  it  fills  up  a  gap  that 
existed  in  former  classifications  of  mental  symptoms.  It  represents  the 
negation  of  mentalization  resulting  from  disease,  where  the  patients  are 
insensible  to  external  influences,  Avill  not  speak,  where  the  faculty  of 
attention  appears  to  be  quite  gone,  and  where  they  appear  not  to  think 
or  feel  at  all.  I  can  devise  no  better  name  than  the  usual  one  of  Stupor, 
Amentia  being  already  appropriated  to  Idiocy — which,  by  the  way,  is 


44  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

never  really  mindlessness  as  the  name  would  imply.  "  Psychocoma  " 
would  express  this  condition. 

Inasmuch  as  physiology  has  clearly  demonstrated  the  existence  of 
centres  in  the  nervous  system  that  control  other  nervous  centres,  giving 
the  name  of  inhibition  to  the  function  of  the  former ;  and  we  find  that 
there  are  certain  cases  of  mental  disease,  where  an  analogous  function  of 
the  hiorher  ideo-motor  nerve-centres  seems  to  be  deranged,  where  there 
are,  in  fact,  states  of  want  of  inhibitory  mental  power  without  marked 
depression,  exaltation,  or  enfeeblement,  I  have  put  those  under  a  special 
class,  viz.,  states  of  defective  mental  inhibition.  Those  might  be  called, 
for  the  sake  of  keeping  up  a  scientific  correspondence  in  the  nomenclature, 
Psychokinesia. 

Lastly,  there  is  a  mental  state  graphically  described  by  Dr.  Maudsley, 
and  which  certainly  represents  facts  in  nature,  the  insane  temperament 
or  neurosis  insana,  or,  to  keep  up  uniformity  of  the  classification,  Psy- 
choneurosis.  This  consists  more  of  potentialities  of  psychosis,  of  extra- 
ordinary and  unusual  assortment  of  mental  fiiculties,  of  states  of  feeling 
that  are  unaccountable  and  uncommon,  and  of  courses  of  conduct  that 
seem  merely  automatic,  and  incapable  of  volitional  regulation — all  these 
things  being  the  result  of  a  hereditary  neurosis  in  a  brain  Avhose  various 
functions  and  parts  are  unconformable,  or  whose  dynamical  constitution 
is  unstable  and  eccentric.  The  following  is  the  symptomatological  classi- 
fication I  shall  use  with  the  chief  varieties  of  each  form : 

1.  St  ites  of  Mental  Depression  (3IelanchoIia,  Psychalgid). — a.  Simple 
Melancholia,  h.  Hypochondriacal  Melancholia,  c.  Delusional  Melan- 
cholia, d.  Excited  Melancholia,  e.  Resistive  (obstinate)  Melancholia. 
/.  Convulsive  Melancholia,     g.  Organic  Melancholia,     h.  Suicidal  and 

Homicidal  Melancholia. 

2.  States  of  Mental  Exaltation  {Mania,  Psychlampsid). — a.  Simple 
Mania,  h.  -Acute  Mania,  c.  Delusional  Mania,  d.  Chronic  Mania. 
e.  Ephemeral  Mania  {Mania  Transitoria).     f.  Homicidal  Mania. 

3.  States  of  Regularly  Alternating  Mental  Conditions  {Folie  Circu- 
laire,  Psychorythm,  Folie  a  Double  Forme,  Circular  Insanity,  Periodic 
Mania,  Recurrent  3fania,  JCatatonia). 

4.  States  of  Fixed  and  Limited  Delusion  {Monomania,  Monopsychosis). 
— a.  Monomania  of  Pride  and  Grandeur,  h.  Monomania  of  Unseen 
Agency,     c.  Monomania  of  Suspicion. 

5.  States  of  Mental  Enfeeblement  {Dementia  and  Amentia,  Psycho- 
paresis,  Congenital  Imbecility,  Idiocy). — a.  Secondary  (Ordinary)  De- 
mentia (following  Mania  and  Melancholia),  b.  Primary  Enfeeblement 
(Imbecility,  Idiocy,  Cretinism,  the  result  of  deficient  Brain  Develop- 
ment, or  of  Brain  Disease  in  very  early  life),  c.  Senile  Dementia. 
d.   Organic  Dementia  {the  result  of  gross  Organic  Brain  Disease). 

6.  States  of  Mental  Stupor  {Stupor,  Psychocoma). — a.  Melancholic 
Stupor,  "Melancholia  attonita."  b.  Anergic  Stupor,  "Primary  De- 
mentia," "  Dementia  attonita."  c.  Secondary  'Stupor  {transitory  after 
Acute  3Iania). 

7.  States  of  Defective  Inhibition  {Psychokinesia,  Hyperkinesia,  Im- 
pulsive Insanity,  Volitional  Insanity,  Uncontrollable  Impidse,  Insanity 
without  Delusioti). — a.    General    Impulsiveness,     b.   Epileptiform    Im- 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  45 

pulse.  c.  Animal,  Sexual,  and  Organic  Impulse.  d.  Homicidal 
Impulse,  e.  Suicidal  Impulse.  /.  Destructive  Impulse,  g.  Dipsomania. 
A.  Kleptomania.     ^'.  Pyromania.     k.  Moral  Insanity. 

8.  The  Insane  Diathesis  (Psyclioneurosis,  Neurosis  Insana,  Neurosis 
Spasmodica). 

All  these  varieties  of  mental  disease  find  their  origin  in  and  floAV  out 
of  excess,  defects,  and  irregularities  in  the  physiological  functions  of  the 
brain.  They  may  all  arise  from  innate  morbid  tendencies  in  the  organ, 
or  from  eccentric  causes  within  or  without  the  organism.  The  brain 
responds  by  thought,  by  sympathy,  by  instinctive  and  reflex  influences, 
to  almost  everything  in  the  universe  outside  it,  and  to  every  tissue, 
organ,  and  energy  within  the  organism,  and  no  two  brains  are  alike  in 
their  reactions.  If  its  constitution  is  unsound  therefore,  or  if  its  conditions 
of  energizing  are  unphysiological,  the  causes  being  innumerably  various 
without  and  within  for  aberration  and  derangement,  it  results  that  the 
symptoms  are  almost  as  various  as  the  causes  of  mental  disease.  More 
than  of  any  other  disease,  it  may  be  said  that  no  one  ever  saw  two  cases 
precisely  alike.  This  or  any  other  classification,  therefore,  only  represents 
types  and  genera,  not  species. 

Such  Avas  until  recently  the  usual  mode  of  studying  and  classifying 
mental  diseases.  It  assumes  that  the  mental  symptoms  are  the  chief 
things  about  the  disease  to  be  observed.  The  late  Dr.  Skae,  following 
Morel  and  Schroeder  van  der  Kolk,  devised  and  directed  special  atten- 
tion to  another  mode  of  looking  at  mental  disease,  which  we  may  call 
the  clinical  method.  It  endeavors  to  take  account  of  causes,  and  of  the 
relationship  the  different  varieties  of  the  disease  have  to  the  great  physi- 
ological periods  of  life,  and  to  the  activities  of  the  body  other  than  the 
mental — in  other  words,  it  regards  the  whole  natural  history  of  the  dis- 
eases. 

The  chief  varieties  of  this  clinical  chissification  (which  includes  the 
pathological  varieties  of  mental  disease)  are  the  following : 

1.  General  Paralysis.  2.  Paralytic  Insanity  {^Organic  Dementia). 
3.  Traumatic  Insanity.  4.  Epileptic  Insanity.  5.  Syphilitic  Insanity. 
6.  Alcoholic  (and  Toxic)  Insanity.  7.  Rheumatic  and  Choreic  Insanity. 
8.  Gouty  (Podagrous)  Insanity.  9.  Phthisical  Insanity.  10.  Uterine 
Insanity.  11.  Ovarian  Insanity.  12.  Hysterical  Insanity.  13.  Mas- 
turbational  Insanity.  14.  Puerperal  Insanity.  15.  Lactational  In- 
sanity. 16.  Insanity  of  Pregnancy.  17.  Insanity  of  Puberty  and 
Adolescence.     18.   Climacteric  Insanity.     19.  Senile  Insanity. 

There  are  a  number  of  more  rare  and  less  important  varieties  of  in- 
sanity, which  I  shall  just  allude  to,  viz. : 

1.  Ansemic  Insanity.  2.  Diabetic  Insanity.  3.  Insanity  from 
Bright's  Disease.  4.  The  Insanity  of  Oxalur-ia  and  Phosphaturia. 
5.  The  Insanity  of  Cyanosis  from  Bronchitis,  Cardiac  Disease,  and 
Asthma.  6.  Metastatic  Insanity.  7.  Post-Febrile  Insanity.  8.  In- 
sanity from  Deprivation  of  the  Senses.  9.  The  Insanity  of  Myxoedema. 
10.  The  Insanity  of  Exophthalmic  Goitre.  11.  The  Delirium  of  Young 
Children.  12.  The  Insanity  of  Lead  Poisoning.  13.  Post- Connubial 
Insanity.     14.   The  Pseudo-Insanity  of  Somnambulism: 

In  studying  mental  diseases,  one  must  constantly  refer  to  the  general 


46 


CLIXICAL    STUDY    OF    MENTAL    DISEASES. 


functions  of  the  brain,  and  I  liave  thought  it  might  be  useful  to  point 
out,  in  the  following  form,  the  bearings  of  some  of  the  most  important 
anatomical,  physiological,  psychological,  and  pathological  considerations 
on  that  study : 


There  is  in  the  brain  an  extreme  com- 
plexity of  tissues,  fibres,  and  groupings, 
and  an  extreme  delicacy  of  structure, 
these  corresponding,  no  doubt,  to  the 
multiformity,  complexity,  and  delicacy  of 
its  functions.  There  is  an  obvious  inter- 
dependence of  parts,  and  a  localization  of 
structures  and  functions,  but  yet  a  real 
solidarity  of  the  whole  brain  in  structure 
and  function. 

There  is  the  most  direct  connection, 
structurally  and  functionally,  of  every 
organ  and  of  every  tissue  with  the  brain 
convolutions,  and  their  influence  is  mu- 
tual, powerful,  and  constant. 

Developmentally  and  functionally  one 
nervous  ganglion  or  group  of  cells  is 
"higher"  than  another,  and  controls  or 
stops  its  action. 

Looking  at  a  brain  convolution,  its 
nerve  cells  differ  in  shape  and  size.  They 
are  placed  in  distinct  layers,  and  arranged 
in  groups.  They  have  been  demonstrated 
to  be  different  in  appearance  in  young 
children,  in  idiots,  in  old  persons,  and  in 
many  cases  of  insanity,  from  what  they 
are  in  a  healthy  adult  (see  Plate  VIII., 
Pigs.  2,  3,  and  4). 

There  is  reason  to  suppose  that  many 
parts  of  the  brain  convolutions  can  ener- 
gize in  different  ways,  one  part  being 
capable  of  doing  the  work  ordinarily 
done  by  another ;  and  every  part  of  the 
brain  is  double. 

The  brain  has  a  reflex  and  automatic 
action.  Most  of  its  functions  are  affected 
by  this,  and  may  be  excited  into  activity 
or  may  be  disturbed  in  a  reflex  manner 
by  indirect  stimuli,  like  the  heart  from 
stomach  derangement.  Most  of  the  re- 
flex functions  of  the  brain  may  be  unat- 
tended by  consciousness;  or  conscious- 
ness without  volition  may  be  present  in 
regard  to  mental  acts  and  to  subsequent 
muscular  action. 

The  study  of  the  physiological  condi- 
tions of  sleep,  dreaming,  and  hypnotism, 
are  most  important,  though  as  yet  many 
of  the  phenomena  are  v.ery  obscure. 

Consciousness  may  be  complete,  par- 
tial, or  abolished  in  health. 

The  brain  has  fixed  limits  of  energiz- 
ing in  all  directions. 


All  sorts  of  sensations,  we  must  keep 
in  mind,  are  subjective,  and  depend  on 


Hence  we  are  apt  to  have  many  func- 
tions and  structures  involved  in  mental 
diseases — motor, sensory,  vaso-motor,  and 
trophic.  Localization  is  never  complete, 
and  solidarity  is  never  perfect. 


Hence  peripheral  lesions  and  disor- 
dered functions  of  organs  cause  mental 
disturbance,  and  vice  versa. 


Hence  disorder  of  the  higher  centres  is 
far  more  important  than  of  the  lower. 


Hence  we  have  a  structural  basis  for 
certain  forms  of  insanity,  and  for  limited 
mental  affections. 


If  this  is  so,  damage  to,  or  exhaustion 
of,  one  portion  of  brain  convolutions  [as 
in  Goltz's  and  Nothnagel's  experiments], 
need  not  necessarily  cause  irretrievable 
loss  of  mental  functions. 

In  mental  disease,  this  reflex  function 
of  the  brain  plays  a  most  important  part. 
Many  symptoms  can  only  be  rightly  ex- 
plained through  it.  In  many  mental 
diseases  the  brain  acts  automatically,  even 
suicidal  and  homicidal  impulses  taking 
place,  the  volition  and  the  consciousness 
being  absent. 


The  psychological  facts  of  those  condi- 
tions should  be  kept  in  mind  in  studying 
mental  disease.  No  phenomena  of  the 
latter  are  more  obscure  than  those  of  the 
former. 

In  mental  disease  we  see  those  condi- 
tions from  pathological  causes. 

Hence  the  danger  of  causing  disturb- 
ance or  paralysis  of  function  by  coming 
too  near  those  limits,  or  overstepping 
them. 

Sensations  can  be  misinterpreted,  there- 
fore, in  mental  diseases,  and,  as  a  matter 


CLINICAL    STUDY    OF    MENTAL    DISEASES. 


47 


consciousness.  The  real  import  of  most 
sensations,  special  and  common,  was 
origiriallj'  only  learned  slowly  and  by  in- 
terpretation and  experience  in  childhood. 
There  is  a  tendency  in  the  brain  to 
propagation,  dift'usion,  and  extension  of 
action,  normal  and  abnormal,  and  there 
is  much  trophic  solidarity  in  the  whole 
brain,  its  envelopes,  and  the  nerves  con- 
nected with  it,  quite  independently  of 
whether  the  tissues  are  cellular  or  fibrous, 
or  whether  the  function  is  originating  or 
conducting. 


Every  mental  manifestation,  normal 
or  abnormal,  must  be  assumed  to  take 
place  directly  through  the  energizing  of 
the  brain  convolutions. 


Mentalization  differs  so  enormously  in 
degree,  form,  and  intensity  in  diflerent 
human  beings,  in  the  two  sexes,  and  in 
different  races,  and  at  different  ages,  that 
any  correct  standard  of  mental  health 
must  allow  an  enormous  margin  of  psy- 
chological difference,  apart  altogether 
from  disease. 

The  action  of  "mind  on  mind"  in 
healthy  brains  is. direct,  intense,  and  most 
subtle. 

The  quality,  the  power  of  energizing 
and  of  resistance,  the  mode  of  working, 
the  liability  to  disease,  and  the  recupera- 
tive power  of  the  convolutional  brain 
tissue,  are  probably  determined  more 
largely  in  any  individual  by  his  heredity 
than  by  any  other  cause.  Bad  heredity 
may  affect  the  whole  brain  and  all  its 
functions,  or  only  a  part  of  them. 

The  chief  of  the  human  instincts,  appe- 
tites, and  organic  necessities  are — 

1.  Love  of  life,  with  efforts  to  prolong 
it. 

2.  Desire  to  reproduce  the  species. 

3.  Love  of  offspring,  with  efforts  to 
nourish  and  protect  it. 

4  Social  instincts  in  innumerable 
forms. 

5.  Necessity  to  energize. 

6.  Appetite  for  food  and  drink. 
Many  of  these  are  periodic  in  their  in- 
tensity or  occurrence. 

The  chief  faculties,  looked  at  from  the 
mental  point  of  view,  are  consciousness, 
perception,  ideation  and  judgment,  voli- 
tion and  mental  inhibition,  affective  fac- 
ulty or  all  that  relates  to  feeling  and 
emotion,  memory,  power  of  attention,  re- 
presentation and  imagination,  association 
of  ideas,  and  speech. 


of  fact,  many  insane  delusions  arise  in 
that  way. 


This  takes  place  abnormally  in  disor- 
dered working  of  the  organ,  disordered 
functional  conditions  extending  from  the 
encephalic  tissue  regulating  one  function 
to  that  regulating  others.  There  is  a 
strong  tendency  to  progressive  patholog- 
ical propagation  of  diseased  processes  in 
the  brain  and  along  the  nerves.  Many 
forms  of  insanity  are,  no  doubt,  explained 
in  this  way.  Usuall}-  the  functional 
propagations,  like  the  structural  degen- 
erations, take  place  in  the  line  of  physio- 
logical function. 

Hence,  wherever  the  "  origin  "  of  men- 
tal disease  may  be,  or  whatever  may  be 
its  "causes,"  mental  or  physical,  its  im- 
mediate cause  and  seat  must  be  in  the 
disordered  energizing  of  the  brain  con- 
volutions. 

Hence  the  necessity  for  special  inquiry 
as  to  the  normal  mental  power,  the  nor- 
mal mode  of  working,  the  temperament 
and  the  diathesis  in  every  case  of  mental 
diseases  one  has  to  study  or  treat. 


The  same  is  the  case  when  the  hrain  is 
disordered,  and  hence  in  psychiatry  men- 
tal therapeutics  are  a  most  important 
moans  of  treatment. 

Hence  the  importance  of  a  study  of 
heredity  in  mental  disease.  In  some 
form,  direct  or  indirect,  it  is  rarely  ab- 
sent in  any  case. 


In  every  case  of  insanity,  attention  and 
inquiry  must  be  directed  as  to  whether 
any  of  these  are  impaired,  paralyzed,  or 
perverted,  or  whether  their  normal  peri- 
odicity is  interfered  with. 


It  is  important  in  examining  a  case  of 
mental  disease  to  go  over  these  systemat- 
ically and  test  how  they  are  affected,  be- 
cause they  are  affected  in  different  ways 
and  degrees  in  different  cases. 


48 


CLINICAL    STUDY    OF    MENTAL    DISEASES. 


The  great  physiological  periods  or  crises 
of  lite  (dentition,  puberty,  adolescence, 
the  climacteric,  and  senility),  and  the 
great  rejirodiictive  activities  (menstrua- 
tion, ovulation,  coitus,  preijnancy,  nurs- 
iniij  and  care  of  children),  bring  into  in- 
tense activity,  or  throw  out  of  action 
wholly  or  partially,  great  tracts  of  con- 
voliitional  brain  tissue. 

Diseased  or  undeveloped  function  is 
apt  to  be  folk  wed  by  atrophied  structure, 
and  prolonged  disturbance  of  function  by 
change  of  structure. 

The  mode  of  energizing  of  nervous  tis- 
sue is  normally  spasmodic,  and  even  explo- 
sive, in  regard  to  certain  functions.  This 
quality  is  especially  developed  in  badly 
constituted  brains.  There  is  reason  to 
suppose  that  only  comjiaratively  limited 
portions  of  the  brain  can  be  in  actit)n  at 
the  same  time,  and  that  even  the  whole 
of  the  iieurine  tissue  subserving  the  same 
limited  function  does  not  all  come  into 
activity  at  once. 

The  blood  supply  of  the  brain  is  enor- 
mous (one-fifth  of  whole  body),  and  of 
the  gray  matter  of  the  convolutions  live 
times  the  amount  of  the  white.  The 
gray  matter  needs,  and  uses  up,  far  more 
blood  than  any  other  tissue  in  the  body 
in  proportion  to  its  bulk.  The  vascular 
sujtply  of  the  brain  is  derived  from  dif- 
ferent sources.  The  wliole  encephalon  is 
divided  more  or  less  into  vascular  areas, 
each  area  having  slight  anastomosis  with 
its  surrounding  areas.  It  is  not  yet 
proved,  but  it  is  probable,  that  those  areas 
are  co-related  to  different  functions.  The 
whole  conditions  of  the  blood  supply  to 
the  brain  and  within  the  head,  are  f)ecu- 
liar  and  different  from  any  other  part  of 
the  body  from  its  being  in  a  shut  box  not 
subjected  to  the  pressure  of  the  atmos- 
phere, except  through  the  vascular  open- 
ings and  foramen  magnum,  and  from  its 
peculiar  relation  to  the  cerebro-spinal 
fluid.  The  lymphatic  spaces  are  also 
peculiar  in  the  brain,  and  no  doubt  affect 
its  circulation  and  nutrition.  The  vessels 
of  the  brain,  large  and  small,  are  delicate, 
have  little  support  but  the  pressure  of  a 
shifting  fluid  ;  and  the  cardiac  and  vas- 
cular pressure  and  tension  are  constantly 
varying.  It  would  seem  as  if  mental 
emotions  had  a  more  direct  and  powerful 
influence  on  the  vessels  of  the  head  than 
on  those  of  almost  any  other  part  of  the 
body,  e.  g.,  in  blushing,  etc. 

The  various  envelopes,  protecting,  and 
packing  tissues  of  the  brain,  are  most  im- 
portant in  themselves  and  in  their  normal 
relationship  to  the  brain.  They  derive 
their  blood  supply  from  the  same  sources. 


Hence  these  are  very  apt  to  be  attended 
with  danger  to  the  normal  mental  bal- 
ance when  the  convolutional  tissue  is  bad 
in  quality,  unstable,  or  badly  nourished, 
or  specially  liable  to  morbid  explosions  of 
energizing.  In  every  case  of  mental  dis- 
ease the  possible  influence  of  these  should 
be  inquired  into. 

Hence  prolonged  mental  enfeeblement 
is  followed  by  l»rain  atrophy  and  pro- 
longed mental  disturbance  by  structural 
brain  changes. 

This  explains  in  some  degree  the  phe- 
nomena of  mental  morbid  explosions  and 
functional  defects  being  suddenly  devel- 
oped when  the  structural  cause  has  been 
a  gradually  advancing  one,  e.  g..,  we  see 
sudden  mania,  or  paralysis,  or  convul- 
sion, or  unconsciousness  resulting  from 
softenings  or  sclerosis,  or  inflammation, 
that  have  been  going  on  gradually  for  a 
long  time  till  they  reached  a  certain  point 
beyond  which  function  could  nut  be  per- 
formed. 

Hence,  when  in  certain  f'>rms  of  men- 
tal disease  there  is  congestion  or  vaso- 
mot'^r  dilatation  of  those  already  crowded 
capillaries,  we  have  serious  effects  on  the 
neurine  and  its  functions.  Nothing  is 
more  common  after  death  in  insanity 
than  to  find  the  brain  substance  divided 
into  distinct  vascular  and  antemic  areas 
(Plate  II.).  Certain  morbid  appearances 
(e.  (J.,  "  pachymeningitis  hajinorrhagica 
interna")  are  found  within  the  skull, 
whit'h  are  not  found  elsewhere  at  all. 
The  lymphatic  spa(!es  are  often  found 
blocked  up  by  debris.  Capillary  hemor- 
rhages (Plate  VII.,  Fig.  2)  are  most  com- 
mon in  in.-anitv ,  and  vascular  di.-ease  is 
most  common,  and  should  always  be 
looked  for,  in  those  who  die  mentally 
affected. 


In  mental  disease  we  often  find  more 
evident  and  constant  disease  in  the  bones, 
membranes,  neuroglia,  and  epithelial  lin- 
ings of  the  ventricles  than  in  the  brain 
itself.  "When  diseased  they  affect  the  neu- 
rine secondarily,  or  are  affected  by  its  dis- 
eases (see  Plates  IV. and  VII., Figs.  1,2). 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  49 

It  may  be  said  generally  that  inflam-  Hence  we  must  specially  examine  those 

mation  and  new  pathological  formations  packing    and    vascular    tissues,    and    we 

— tubercle,  syphilis,  cancer,  etc. — show  a  often  find  that  though  they  are  affected 

greater  affinity   for   the  packing   tissues  primarily  by  those  new  pathological  for- 

and  bloodvessels  than  for  the  brain  itself,  mations,  yet  the  neurine  has  suffered  as 

while  the  progressive  degenerations  tend  much,  structurally  and  functionally,  as  if 

more  to  affect  the  true  nerve  tissue.  it  had  been  first  affected. 

As  to  the  general  method  of  clinically  examining  a  patient,  insane  or 
supposed  to  be  insane,  the  following  rules  ma}'^  be  of  service: 

1.  Get  all  the  information  about  him  you  can  beforehand,  and  from 
the  most  direct  sources,  especially  on  the  folloAving  points:  his  heredity, 
temperament,  habits,  and  what  sort  of  man  he  was,  and  what  delusions 
he  labors  under,  how  he  is  changed  from  his  former  self,  whether  he  is 
morbidly  suspicious  and  will  resent  a  medical  examination,  whether  he  is 
suicidal  or  dangerous,  Avhether  his  power  of  self-control  is  affected  and  in 
what  way,  and  his  weak  points  mentally — get,  in  fact,  a  good  concise 
history  of  his  case,  especially  noting  the  first  symptoms  and  the  general 
course. 

2.  In  your  interviews  be  in  manner  natural,  frank,  honest,  fearless, 
sympathetic,  and  a  good  listener,  assuming  outwardly  that  your  patient 
is  sane.  Do  not  be  afraid  to  lead  up  to  his  delusions  and  mental  weak 
points  after  you  have  gained  his  confidence  and  interest.  Do  not  con- 
tradict or  irritate  until  you  want  to  test  his  self-control.  Do  not  deceive 
him  if  possible.  After  you  have  satisfied  yourself  he  is  ill,  try  and 
make  him  believe  it  too.  Take  time ;  few  satisfactory  first  examinations 
can  be  conducted  in  a  hurry. 

3.  Look  on  his  speech,  manner,  and  appearance  as  being,  in  them- 
selves, possible  symptoms  of  his  disease;  be  all  the  time  in  a  quiet  sys- 
tematic way,  unobserved  by  the  patient,  testing  his  mental  faculties  (see 
p.  47)  seriatim  in  your  own  mind,  and  be  on  the  look-out  for  insane 
delusions  or  suspicions,  depression  of  mind,  exaltation,  enfeeblement, 
lethargy  and  stupor,  or  altered  feeling  towards  relatives  and  friends. 

4.  Note  carefully  the  expression  of  face  and  eyes,  the  articulation,  the 
manner,  the  muscular  movements,  the  writing  if  possible,  the  nutrition 
of  the  body  and  the  conformation  of  head. 

5.  Examine  the  state  of  the  pulse  and  temperature.  Never  think  any 
examination  complete  without  taking  the  temperature.  Many  patients 
laboring  under  the  delirium  of  fevers  and  inflammations  would  have  been 
saved  from  being  sent  to  asylums  had  this  been  done.  Examine  into  the 
condition  of  tongue,  appetite,  digestion,  bowels,  and,  in  fact,  go  over  all 
the  great  bodily  functions.  Especially  find  out  about  the  sleep — whether 
he  sleeps  at  all,  what  kind  of  sleep,  and  for  how  long,  and  whether  he 
dreams,  and  of  what  character  the  dreams  are;  usually  the  sleep  is 
"broken"  and  unrestful  in  the  early  stages  of  insanity,  the  patients 
dream  much,  and  the  dreams  are  unpleasant.  Examine  into  the  motor 
and  sensory  functions  of  the  brain  and  cord,  especially  asking  about 
headaches  and  neuralgic  pains.  Always  remember  that  the  ordinary 
symptoms  of  bodily  disease  may  be  masked  by  the  brain  condition,  so 
that  lung  and  visceral  diseases,  injuries,  etc.,  may  exist  without  any  con- 
sciousness of  the  patient  or  any  olivious  symptom  whatever. 

4 


50  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

6.  Remember  there  are  three  aspects  to  every  case  of  insanity — the 
medical,  which  concerns  you  as  a  physician  about  to  treat  a  patient;  the 
medico-legal,  which  concerns  you  and  the  patient  in  regard  to  depriving 
him  of  his  liberty  and  of  the  control  of  his  affairs,  and  affects  his  respon- 
sibility to  the  law ;  and  the  medico-psychological,  which  includes  all  the 
mental  problems  that  arise  in  a  study  of  the  case. 

7.  Always  pass  before  your  minds  the  following  conditions,  and  by 
exclusion  determine  that  the  case  is  not  one  of  them,  viz.,  drunkenness, 
drugging  by  opium  or  other  narcotics,  meningitis,  cerebritis,  brain  syphilis, 
the  fevers,  sunstroke,  traumatic  injury  to  head,  hysteria,  the  cerebral 
effects  of  gross  brain  diseases,  simple  delirium  tremens,  the  temporary 
cerebral  effect  of  moral  shock,  or  the  delirium  that  precedes  death  in 
many  diseases  and  in  old  age.  I  have  had  cases  of  drunkenness,  menin- 
gitis, typhus  and  typhoid  fevers,  hysteria,  apoplexy,  delirium  tremens, 
and  the  delirium  preceding  death,  sent  into  asylums  under  my  care,  as 
laboring  under  ordinary  insanity,  and  have  heard  of  the  other  conditions 
being  so  mistaken.  Many  of  these  conditions  and  diseases  may,  how- 
ever, lead  to,  or  be  associated  with,  real  mental  disease,  and  require 
treatment  as  such. 

8.  In  the  clinical  study  of  mental  diseases,  try  and  look  on  all  the 
abnormalities  present,  mental  and  bodily,  as  being  symptoms  of  the  dis- 
ease, and  essential  parts  of  the  brain  disturbance  present,  and  not  as 
mere  accompaniments.  For  instance,  in  a  case  of  puerperal  insanity,  it 
is  not  merely  the  delusions  and  mental  exaltation  that  are  the  disease, 
but  the  high  weak  pulse,  the  raised  temperature,  the  glistening  eye,  the 
constant  muscular  motion,  the  dry  tongue,  the  uterine  tenderness,  the 
absence  of  lochia,  the  sleeplessness,  the  paralysis  of  appetite,  are  all 
symptoms  of  the  disease  in  a  true  sense — that  is,  they  are  all  results  or 
essential  concomitants  of  the  brain  disturbance,  of  which  the  mental 
symptoms  are  the  most  striking  features. 

9.  The  patient's  account  of  himself  is  not  always  to  be  relied  on.  He 
may  be  dying,  and  yet  to  his  consciousness  have  no  symptom  of  it,  so 
that  he  tells  you  he  never  was  better  in  his  life;  his  bowels  may  have 
been  moved  freely  that  morning,  and  yet  he  tells  you  he  has  not  had  a 
motion  for  a  week ;  he  may  not  be  able  to  Avrite  a  line,  yet  he  says  he 
never  wrote  so  well  in  his  life,  etc.  You  must,  through  your  reasoning, 
medical  examination,  and  observation,  find  out  what  is  true  and  what  is 
delusion.  I  had  once  a  case  where  a  medical  man  certified  as  a  delusion 
what  an  examination  would  have  shown  him  to  be  a  fact,  viz.,  that  the 
patient  was  pregnant.  Certain  things  of  the  greatest  import  in  a  case  of 
insanity  the  patient  is  very  apt  to  deny,  such  as  suicidal  feelings,  mastur- 
bation, etc. 

10.  It  may  be  needful  in  some  cases  for  the  patient's  safety,  or  that  of 
his  relations,  or  for  the  preservation  of  his  property,  to  practise  some 
amount  of  concealment  of  your  profession,  and  of  the  object  of  your  visit. 
The  man  knows  so  well  what  a  doctor's  visit  means  that  he  will  not  see 
a  doctor  if  he  knows  him  to  be  one,  or  he  is  so  dangerous  and  cunning 
that  needless  risk  would  be  run  by  announcing  to  him  the  object  of  your 
visit.     But  the  public  and  the  friends   of  patients  have  often  a  most 


CLINICAL    STUDY    OF    MENTAL    DISEASES.  51 

needless  desire  tliat  you  should  practise  guile  where  there  is  no  necessity 
in  the  world  for  it.  As  a  general  rule,  there  is  not  much  to  fear  from 
the  insane  of  the  respectable  classes  of  society.  But  cunning  and  sus- 
picion are  the  marked  characteristics  of  many  of  those  affected  in  mind. 

11.  Negative  symptoms — silence,  obstinacy,  stupidity,  etc. — are  to  be 
noted  and  are  valuable  in  diagnosis  and  treatment- 

12.  Compare  mentally  the  man  as  you  see  him  with  the  man  you  may 
have  known  or  had  described  to  you. 

13.  The  chief  questions  you  ask  yourself,  and  the  main  problems  that 
you  have  to  solve,  are  the  following :  Is  the  man  mentally  affected  or 
not  ?  If  so,  is  he  sufficiently  affected  to  be  regarded  as  legally  insane 
and  irresponsible  ?  What  form  of  insanity  does  he  labor  under  ?  Can 
the  brain  disease  be  localized  or  its  pathological  character  determined  ? 
What  is  to  be  the  treatment  ?  What  risks  are  there  in  the  case,  e.  g.,  of 
suicide,  danger  to  others,  convulsions,  paralytic  attacks,  exhaustion, 
refusal  of  food,  or  sudden  death  ?  What  is  the  general  prognosis  ?  How 
long  Avill  it  be  before  the  case  recovers  or  dies  ?  Is  home  treatment 
suitable  or  safe?  or  must  the  case  be  removed  from  home  to  the  country, 
or  to  a  hospital  for  the  insane  ?  Can  trained  reliable  attendance  be  got  ? 
W  hat  mental  therapeutics  must  be  adopted,  cheering  or  soothing,  divert- 
ing, reassuring,  checking,  agreeing  with  him,  contradicting  him,  or  avoid- 
ing his  favorite  topics  ? 

14.  It  is  always  well,  in  a  case  of  mental  disease,  to  make  the  relations 
or  guardians  of  the  patient  very  full}'^  acquainted  with  the  risks  of  the 
case,  to  keep  them  hopeful  if  there  is  any  hope,  to  give  the  patient  the 
benefit  of  all  doubts,  to  guard  yourself  in  prognosis,  remembering  that 
our  knowledge  of  mental  disease  is  imperfect,  and  that  the  most  experi- 
enced of  us  are  deceived  sometimes,  and  that  there  are  few  rules  in  regard 
to  brain  disorders  to  which  there  are  not  exceptions,  to  take  no  more  re- 
sponsibility about  sending  a  patient  to  an  asylum,  for  instance,  than 
fairly  can  be  laid  on  a  medical  man,  making  the  relatives  take  their 
proper  share.  It  is,  as  a  general  rule,  better  not  to  be  too  explicit  about 
the  time  it  may  take  a  patient  to  recover.  If  you  undertake  the  treat- 
ment at  home,  or  in  a  private  house,  only  do  so  on  the  understanding 
that  the  nurses  or  attendants  are  under  your  exclusive  orders.  If  you 
have  to  sign  a  certificate  of  insanity  for  placing  a  patient  in  an  asylum, 
or  taking  the  management  of  his  affairs  out  of  his  hands,  remember  there 
is  often  a  legal  risk  to  yourself  from  the  patient  bringing  an  action  against 
you,  a  risk  that  in  some  rare  cases  it  is  well  to  avoid  by  even  getting  a 
letter  of  indemnification  from  a  relation  before  you  sign  it. 

15.  In  regard  to  the  question  of  home  or  asylum  treatment,  it  depends 
on  many  other  things  as  well  as  the  patient's  condition.  His  means  are 
the  first  of  these.  Home  or  private  house  treatment  of  a  case  of  mental 
disease  is  mostly  expensive  from  the  skilled  attendance  needed.  In  the 
midst  of  a  city,  home  treatment  of  almost  any  case  is  most  difficult. 
Home  treatment  is  often  impossible  from  the  associations  and  surround- 
ings aggravating  the  disease.  If  there  is  a  very  intense  suicidal  tendency, 
the  risks  cannot  well  be  obviated  in  a  private  house.  If  there  is  noise, 
maniacal  excitement,  or  constant  muscular  motion,  a  private  house  is 


52  CLINICAL    STUDY    OF    MENTAL    DISEASES. 

seldom  a  proper  place  for  long.  In  a  good  hospital  for  the  insane,  most 
of  the  means  of  treatment,  safety,  skilled  attendance,  regular  exercise,  a 
proper  mode  of  life,  the  administration  of  food  and  medicines,  can  no 
doubt  be  best  attained,  but  then  there  are  the  counterbalancing  disadvan- 
tages of  the  harm  to  the  patient's  prospects,  from  the  cruel  popular  pre- 
judices about  asylums,  and  the  patient's  own  feelings  about  it  afterwards. 
If  you  can  treat  a  case  out  of  an  asylum,  and  he  recovers  satisfactorily, 
it  is  better  for  you  and  him. 


LECTURE     II. 

STATES  OF  MENTAL  DEPRESSION— MELANCHOLIA  {PSYCHALGIA). 

All  the  morbid  states  of  depressed  feeling,  or,  as  more  commonly  ex- 
pressed, of  mental  depression,  are  comprised  under  the  term  Melancholia. 
Like  the  other  symptomatological  varieties  of  mental  disease,  melancholia 
does  not  admit  of  an  absolutely  precise  definition.  In  every  case  there 
must  be  mental  pain,  hence  I  have  suggested  as  an  alternative  the  term 
Psychalgia,  but  then  mental  pain  does  not  alone  constitute  melancholia. 
As  man's  experience  goes  in  the  world  at  present,  mental  pain  scarcely 
implies  the  idea  of  disease  at  all.  The  causes  and  occasions  of  mental 
pain  from  within  and  without  are  so  common,  as  most  men  are  now  con- 
stituted and  situated,  that  its  presence  is  the  rule  with  many,  and  its 
entire  absence  the  exception  with  most.  To  constitute  melancholia  there 
must  be  disorder  of  brain  function.  A  man's  finger  is  squeezed  in  a  vice, 
and  he  feels  the  most  intense  pain,  but  we  do  not  call  that  neuralgia.  He 
loses  a  child  or  a  fortune,  and  feels  intense  mental  pain,  but  we  do  not  call 
it  melancholia,  because  there  is  no  disease.  All  brain  reactions  mentally 
in  obedience  to  adequate  causes  are  simply  the  exercise  of  physiological 
function,  but  when  the  reaction  is  quite  out  of  proportion  to  the  cause, 
or  when  the  exercise  of  the  activity  of  the  brain  induces  mental  pain  of 
a  certain  intensity  and  kind  without  any  outside  cause,  then  we  conclude 
that  the  mental  portion  of  the  organ  is  disordered,  and  we  say  that  the 
patient  suffers  from  melancholia.  There  may  be  in  the  case  certain  ex- 
citants wrongly  called  causes — mental,  moral,  or  physical.  The  man 
may  have  committed  crimes,  or  he  may  have  a  badly  acting  liver,  or  he 
may  be  very  anaemic,  and  all  these  things  may  cause  mental  pain  and 
depression  in  a  healthy  brain,  but  they  will  not  cause  them  in  that 
amount  and  kind  to  constitute  melancholia  till  his  brain  convolutions 
have  taken  on  a  disordered  action — until  their  dynamical  state  is  that  of 
disease,  not  that  of  health.  If  a  man's  heart  is  depressed  in  its  action 
from  a  fright,  we  do  not  give  this  a  name  implying  disease,  unless  the 
depression  goes  on  long  after  the  cause  has  ceased  to  act.  This  illus- 
trates, too,  the  weak  points  of  the  method  of  classifying  mental  diseases 
from  mental  symptoms  alone.  It  is  as  if  in  cardiac  diseases  we  should 
classify  them  as  syncopes,  palpitations,  and  anginas.  Therefore,  we 
must  always  keep  in  mind,  in  using  such  terms  as  melancholia,  that  the 
mental  symptoms  are  not  the  disease ;  we  must  always  consciously  refer 
those  symptoms  to  the  brain  convolutions  in  the  diagnosis  and  treatment 
of  mental  diseases,  which  are  simply  brain  disorders  of  different  kinds  in 
which  the  mental  symptoms  predominate.  In  assigning  causes,  we  may 
say  that  peripheral  irritations,  anaemias,  and  moral  and  mental  shocks 
have  caused  the  disease;  but  we  must  clearly  keep  in  mind  that  the 


54  STATES    OF    MENTAL    DEPRESSION. 

mental  symptoms  of  the  disease  are  caused  bj  the  disordered  working  of 
the  encephalic  tissue.  If  that  remains  sound  in  structure  and  working, 
no  amount  of  aneemia  or  moral  shock  will  cause  any  real  mental  disease. 

States  of  mental  depression  are,  in  some  of  their  forms,  of  all  mental 
diseases  those  that  are  nearest  mental  health.  They  shade  off  by  imper- 
ceptible degress  into  mere  physiological  conditions  of  mind  and  brain. 
To  be  able  to  feel  ordinary  pain  implies  an  encephalic  tissue  for  the  pur- 
pose. To  be  very  sensitive  to  pain  implies  that  the  tissue  is  acutely 
receptive  of  impressions.  So  with  mental  pain  there  can  be  no  doubt 
that  the  healthy  physiological  condition  of  the  encephalic  tissue  in  the 
brain  convolutions  through  which  ordinary  or  mental  pain  is  felt  is  one 
between  extreme  callousness  to  impressions  and  extreme  sensitiveness. 
A  man  in  robust  health,  well  exercised,  does  not  feel  pain  nearly  so 
acutely,  and  bears  it  better  than  when  he  is  weak  and  run  down.  Those 
principles  apply  equally  to  the  feeling  and  the  bearing  of  mental  pain. 
To  experience  emotion  at  all — to  feel — implies  an  encephalic  structure 
for  this  purpose.  The  most  casual  study  of  the  affective  capacity  in 
human  beings  shows  us  that  it  differs  enonnously  in  different  persons. 
One  man  will  lose  his  children  or  his  fortune,  or  see  tlie  most  terrible 
sights,  and  he  will  not  feel  keenly  at  all,  because  his  brain  convolutions 
that  subserve  feeling  are  not  in  their  essential  nature  very  receptive  and 
sensitive.  Another  person  will  be  thrown  into  very  great  grief,  and  feel 
acute  agony,  at  the  loss  of  a  favorite  dog.  I  had  a  lady  patient  once, 
A.  A.,  who  would  be  for  days  depressed,  and  suffer  mentally,  if  a  friend 
did  not  receive  her  as  cordially  as  usual  any  day.  She  suffered  mental 
torture  if  a  relative  spoke  sharply  to  her,  and  she  was  absolutely  para- 
lyzed in  feeling  and  volition  by  the  death  of  a  sister.  She  had  several 
attacks  of  mild  melancholia  produced  by  most  inadequate  causes,  from 
all  of  which  she  recovered  quickly  and  completely.  There  can  be  no 
doubt  whatever  that  the  finer  moulds  of  brain  are  mostly  very  sensitive, 
and  the  poetic,  emotional,  and  sympathetic  natures  have  always  been 
subject  to  states  of  painful  depression  of  mind  at  tlie  critical  periods  of 
life,  and  when  the  physical  vigor  was  below  par.  Half  the  poets  and 
men  of  literary  genius  give  ample  proof  in  their  writings,  and  in  the 
characters  they  have  created  or  founded  on  their  own  experience,  that 
they  suffered  at  times  intense  mental  pain.  Goethe  clearly  looked  on  a 
period  of  melancholy  as  one  phase  in  the  development  of  genius.  The 
lives  and  writings  of  Goethe,  Schiller,  Carlyle,  Cowper,  John  Stuart 
Mill,  Byron,  Burns,  and  George  Elliot  shoAv  that  they  all  had  periods  in 
their  lives  when  they  suffered  intense  mental  pain,  and  at  least  one  of 
them  did  actually  pass  the  undefined  borderland  that  separates  physio- 
logical mental  depression  from  pathological  melancholia.  To  feel  intense 
mental  pain  is  mostly  the  necessary  accompaniment  of  the  capacity  to 
feel  intense  joy.  The  brain  qualities  that  give  intensity  to  the  one  give 
also  intensity  to  the  other. 

We  must  take  into  consideration  in  every  case  not  only  the  sensitive- 
ness and  the  receptivity,  but  also  the  power  of  bearing  pain — the  inhibi- 
tory power  against  pain.  Some  brains  possess  great  sensitiveness  and 
also  great '  power  of  inhibition.  Those  are  the  strong  brains,  even 
though  their  temperament  and  diathesis  may  handicap  them.     But  when 


STATES    OF    MENTAL    DEPRESSION.  55 

a  brain  is  sensitive,  and  has  little  inhibitory  power,  this  combination  is  a 
source  of  weakness  and  of  disease. 

There  is  a  morbid  constitution  and  a  temperament  which  predisposes 
to  mental  pain,  but  that  docs  not  readily  feel  intense  pleasure,  and  this 
is  common  enough  among  common  men.  It  does  not  imply  genius  or 
strength  in  any  way,  and  has  no  compensating  advantages  to  its  pos- 
sessors. Persons  with  this  tendency  are  of  the  nervous  variety  of  the 
melancholic  temperament,  or  perhaps,  more  properly  speaking,  have  the 
melancholic  temperament  and  the  nervous  diathesis.  They  are  liable  to 
lose  their  sense  of  well-being  from  slight  causes  from  within  and  without 
them.  This  surplus  stock  of  animal  spirits  and  vis  nervosa  is  soon  ex- 
hausted. They  want  mental  balance  and  resistive  poAver.  They  are 
very  often  persons  with  strong  unreasoning  likes  and  dislikes,  who  are 
swayed  by  their  instincts,  and  cannot  correct  and  guide  those  by  their 
reasoning  poAver.  They  are  often  morbidly  introspective  and  imagina- 
tive, and  very  often  irritable  and  excitable.  Bodily,  they  do  not  lay  on 
fat  at  the  ages  when  fat  is  physiological:  their  digestion  is  not  their 
strong  point;  when  tired,  they  are  sleepless. 

Sflch  a  temperament  and  diathesis  are  strongly  hereditary,  and,  I 
think,  are  very  apt  to  be  derived  in  the  male  sex  from  the  mother,  and 
in  the  female  sex  from  the  father.  It  strongly  predisposes  to  attacks  of 
melancholia  as  well  as  to  attacks  of  mental  depression  in  what  may  be 
called  a  physiological  form  after  many  bodily  diseases.  In  such  persons, 
fevers,  lung  affections,  and  cardiac  troubles  are  apt  to  be  accompanied 
and  to  be  followed  during  convalescence  by  mental  depression.  This  is 
a  serious  complication  in  those  circumstances,  for  it  retards  recovery, 
and  tends  towards  relapses.  It  is,  no  doubt,  another  expression  of  that 
lack  of  trophic  and  recuperative  energy  of  the  brain  which  we  shall  see 
is  so  marked  a  SA'mptom  in  melancholia.  The  great  physiological  crises 
of  life — teething,  puberty,  adolescence,  the  climacteric,  senility,  preg- 
nancy, childbirth,  and  lactation — are  apt  to  be  complicated  by  attacks 
of  the  neuroses  in  such  persons  :  loss  of  blood,  over-work,  want  of  sleep, 
over-anxiety,  and  menstruation  are  also  commonly  accompanied  by  de- 
pression of  spirits.  Children  of  this  brain  constitution  often  exhibit  a 
kind  of  child-melancholy  at  a  very  early  period.  I  have  known  such  a 
child  at  five  years  of  age  become  intensely  depressed,  cry,  and  moan  for 
hours,  because  it  was  afraid  of  the  "hell"  which  its  mother  (of  the  same 
temperament)  had  described  as  being  the  portion  of  bad  boys  who  tore 
their  pinafores,  sinned  against  God,  and  did  not  obey  their  mammas. 
Precocity,  over-sensitiveness,  unhealthy  strictness  in  morals  and  religion 
(for  a  child),  a  too  vivid  imagination,  want  of  courage,  thinness,  and  a 
craving  for  animal  food  are  characteristic  of  such  children. 

It  is  most  difficult  to  draw  a  line  of  definition  between  mere  "lowness 
of  spirits,"  ordinary  "depression  of  mind,"  popular  "melancholy"  or 
"hypochondria,"  and  the  pathological  melancholia.  They  shade  off"  into 
each  other  by  fine  degrees ;  and  yet  it  is  most  important  to  make  a  clear 
distinction.  The  general  public,  who  are  very  fond  of  hearing  profes- 
sional gossip  in  regard  to  medico-psychological  problems,  and  of  retailing 
as  gospel  the  illogical  travesties  and  popularized  versions  of  such  prob- 
lems which  some  professional  men  retail,  have  an  idea  that  those  who 


66  STATES    OF    MENTAL    DEPRESSION. 

have  studied  the  subject  most  deeply  have  come  to  the  conclusion  that 
all  men  are  mad;  and  this  because  we  say  that  no  man  comes  up  to  an 
ideal  standard  of  mind,  and  few  men  but  are  subject  to  mental  depres- 
sion or  excitement,  or  to  lose  their  self-control  at  times.  Such  a  popular 
belief  does  harm,  because  it  is  utterly  opposed  to  fact,  and  tends  toAvards 
confusion  and  misconception  in  regard  to  a  physician's  most  serious 
problems.  It  is  necessary,  therefore,  to  attempt  accurate  definitions, 
even  though  they  may  not  cover  the  whole  ground. 

Mere  melancholy  might  be  defined  as  a  sense  of  ill-being,  and  a  feeling 
of  mental  pain  with  no  real  perversion  of  the  normal  reasoning  power,  no 
morbid  loss  of  self-control,  no  uncontrollable  impulses  towards  suicide, 
the  power  of  working  not  being  destroyed,  and  the  ordinary  interests  of 
life  lessened,  not  abolished. 

Melancholia  might  be  defined  as  mental  pain,  and  sense  of  ill-being, 
more  intense  than  in  melancholy,  with  loss  of  self-control  or  insane  delu- 
sions, or  uncontrollable  impulses  towards  suicide,  with  no  proper  capacity 
left  to  follow  ordinary  avocations,  with  some  of  the  ordinary  interests  of 
life  destroyed,  and  generally  with  marked  bodily  symptoms,  all  these 
things  showing  a  diseased  activity  of  the  highest  brain  centres. 

Typical  cases  exhibiting  these  two  conditions  are  totally  different  and 
distinguishable,  and  the  only  excuses  for  confounding  them  are  that  they 
shade  oif  into  each  other,  that  we  have  no  absolutely  definite  scientific 
test  to  distinguish  them,  that  they  are  both  in  many  cases  the  outcome 
of  the  same  temperament  and  diathesis,  and  that  they  both  have  some- 
thing of  the  same  nature,  both  psychologically  and  physiologically.  A 
typical  case  of  melancholia,  as  we  shall  see,  nins  a  somewhat  definite 
course  like  a  fever,  and  has  often  all  the  characters  of  an  acute  disease, 
in  this  being  to  the  physician  entirely  unlike  a  mere  feeling  of  melancholy. 

Though,  in  the  statistics  of  asylums,  melancholia  does  not  appear  to 
be  the  most  frequent  of  the  varieties  of  mental  disease,  yet  I  think  that 
if  statistics  of  its  real  frequency  in  all  its  forms,  mild  and  severe,  could 
be  got,  it  would  be  found  that  it  is  the  most  common  form.  In  its  milder 
varieties  it  is  a  very  manageable  disease  at  home,  in  this  contrasting 
strongly  with  cases  of  mania.  For  this  reason  many  cases  are  treated 
at  home  and  not  sent  to  asylums  at  all. 

Before  seeing  cases  of  any  disease,  one  should  know  what  to  look  for. 
As  a  general  rule,  one  has  less  difiiculty  in  the  examination  of  a  case  of 
melancholia  than  of  any  other  kind  of  insanity.  The  whole  process  of 
ascertaining  the  symptoms  that  are  present  is  more  like  that  in  any 
bodily  disease.  The  patient  is  usually  conscious  that  there  is  something 
wrong  with  him,  which  is  not  the  case  in  most  forms  of  insanity.  It  is, 
in  fact,  the  sanest  kind  of  insanity.  He  can  describe  some  of  his  symp- 
toms. Many  of  his  subjective  sensations  are  reliable,  and  are  very 
valuable  in  diagnosis  and  treatment.  It  is  not  all  a  process  of  deduction 
from  speech  and  conduct  and  objective  signs.  The  patient  will  tell  you 
in  the  first  place  very  likely  that  he  is  unhappy,  and  feels  mental  pain 
and  depression.  He  will  then  tell  you  why  he  feels  this,  or  if  he  does 
not,  you  ask  him  why  he  is  depressed,  and  then  will  probably  come  out 
the  first  sign  of  mental  unsoundness.  In  nine  cases  out  of  ten,  melan- 
cholic patients  assign  as  a  cause  of  their  misery  what  is  not  its  cause  at 


STATES    OF    MENTAL    DEPRESSION.  57 

all.  Here  it  is  where  their  insane  delusions,  their  false,  ungrounded 
beliefs  come  in.  I  have  analyzed  the  "causes"  assigned  by  melancholies 
that  I  have  had  under  my  care  during  the  past  seven  years  for  their  own 
depression,  and  I  find  them  to  be  Avrong  in  ninety  per  cent,  of  the  cases. 
Melancholia  occurs  in  many  forms,  with  very  various  psychological 
and  clinical  symptoms.  The  following  are,  I  think,  the  most  common 
varieties,  and  I  think  the  study  of  the  disease  will  be  made  easier,  and 
its  treatment  become  more  intelligible,  by  considering  those  varieties 
seriatim,  viz.  : 

a.  Simple  melancholia. 

h.  Hypochondriacal  melancholia. 

c.  Delusional  melancholia. 

d.  Excited  (motor)  melancholia. 

e.  Resistive  (obstinate)  melancholia. 

/.  Epileptiform  (convulsive)  melancholia. 

g.  Organic  (coarse  brain  disease)  melancholia. 

h.  Suicidal  and  homicidal  melancholia. 

Simple  Melancholia. — The  best  way  to  begin  the  study  of  melancholia 
is  to  take  a  case  of  what  may  be  called  simple  melancholia,  that  is,  one 
that  is  both  very  mild  and  uncomplicated,  and  where  the  affective  de- 
pression and  pain  are  far  more  marked  than  the  intellectual  or  volitional 
aberrations.  Such  cases  are  very  common  and  most  of  them  are  never 
sent  to  asylums  or  come  under  the  notice  of  specialists ;  indeed,  many  of 
them  never  come  under  the  notice  of  any  doctor  at  all,  for  it  is  charac- 
teristic of  many  of  them  that  they  have  a  great  disinclination  to  consult 
our  profession.  Such  a  case  as  this  is  a  good  example  :  A.  B.,  a  gentle- 
man of  60,  of  a  neurotic  but  not  insane  stock,  had  inherited  from  his 
mother  a  neurotic  diathesis  and  a  melancholic  temperament,  and  was  of 
a  sensitive,  vivacious,  sympathetic  disposition,  and  very  studious  habits. 
He  had  kept  his  brain  at  full  work  nearly  all  his  life  by  his  ambition  and 
volitional  force.  The  want  of  adjustment  I  count  as  really  an  impei'fec- 
tion  of  brain  constitution ;  the  inhibitory  or  volitional  power  is  so  great 
as  to  force  the  rest  of  the  brain  to  work  or  suffer  longer  than  its  innate 
trophic  or  dynamic  power  would  safely  allow.  In  a  perfectly  ordered 
brain  the  fatigue  of  exhausted  enersizincr  should  be  so  absolute  as  to 
compel  rest.  There  should  be  no  power  in  a  higher  centre  to  compel  a 
lower  centre  to  do  more  than  it  is  fitted  for.  Yet  we  know  that  this  is 
commonly  counted  a  great  power  for  a  man  to  possess — to  be  able  to 
work,  or  think,  or  feel,  or  wake,  or  walk,  not  according  to  his  innate 
capacity  for  these  things,  but  according  to  his  wish  or  the  imagined 
necessity  of  the  occasion.  It  is  a  dangerous  power  for  those  of  a  neurotic 
inheritance.  All  went  on  well  till  A.  B.  was  about  50,  when,  after  a 
big  piece  of  intellectual  work,  he  began  to  feel  that  he  was  always  tired, 
he  had  a  jaded  feeling,  his  work,  instead  of  being  a  pleasure,  became  a 
conscious  toil,  indeed,  he  seemed  capable  of  feeling  no  joy  in  life  any 
more.  It  did  not  quite  amount  to  a  sense  of  ill-being,  but  that  evidence 
and  crown  of  the  perfect  working  of  every  organ,  the  undefinable  but 
very  real  feeling  of  conscious  well-being  had  left  him.     The  common 


68  STATES    OF    MENTAL    DEPEESSION. 

pleasures  of  life,  the  society  of  Lis  wife  and  children  and  friends,  were  no 
longer  delightful ;  indeed,  intercourse  with  his  friends  by  speech  or  letter 
was  distinctly  wearisome,  and  he  avoided  it.  His  courage  was  manifestly 
lessened,  and  he  was  irritable  with  his  children,  an  unusual  thing  with 
him.  It  seemed  to  him  as  if  his  wife  and  children  were  less  consciously 
dear  to  him,  and  this  alarmed  him  and  made  him  ashamed.  He  had  a 
feeling  as  if  he  had  done  something  wrong  to  cause  this — that  it  was  a 
wrong  to  them  in  itself,  and  must  be  a  judgment  on  him  for  some  sin. 
His  favorite  authors  and  poets  seemed  to  have  lost  much  of  their  charm. 
His  religious  duties  brought  little  comfort.  His  appetite  was  dulled; 
food  and  drinks  did  not  tempt  him,  and  after  a  meal  he  was  uncomfort- 
able. His  sexual  desire  was  much  lessened.  Some  of  his  instincts  and 
propensities  seemed  to  be  altered.  His  boAvels  were  costive;  his  skin 
seemed  to  be  harsher  and  drier  than  normal ;  he  had  not  the  same  feeling 
of  reaction  after  cold  bathing ;  he  could  not  sleep  soundly  all  the  night 
through,  and  awoke  unrefreshed :  he  was  losing  weight  a  little. 

But  all  this  time  he  Avas  not  very  thin  or  weak,  and  he  could  appear 
in  public  or  to  his  friends  just  as  usual.  He  had  the  power  to  conceal 
all  his  symptoms  from  those  to  whom  he  did  not  want  them  known. 
There  were  certain  curious  features,  too,  in  his  case.  He  was  always 
worse  in  the  morning — most  persons  with  any  sort  of  mental  pain  are — 
but  if  he  would  set  himself  to  write  a  letter,  or  took  a  brisk  short  walk 
in  the  sunshine,  or  took  a  cup  of  hot  coffee,  he  would  feel  better  and 
happier.  In  the  evenings,  too,  he  would  often,  in  bright  light,  after  a 
good  dinner  with  a  glass  or  two  of  wine,  and  in  the  society  of  friends,  be 
quite  himself  again,  and  feel  almost  gay  for  a  time.  He  stopped  work, 
travelled  and  rested,  and  was  well  in  three  months.  Since  then  he  has 
had  several  such  attacks,  some  of  them  more  severe,  during  which  the 
mental  pain  was  more  positive  and  intense,  the  conscious  mental  prostra- 
tion greater,  and  the  paralysis  of  volitional  energy  more  complete,  so  that 
at  times  he  could  not  possibly  see  his  friends  or  put  on  before  them  any 
appearance  of  cheerfulness.  At  those  times  the  beginnings  of  delusions 
showed  themselves.  He  believed,  and  could  not  correct  the  false  belief 
by  reasoning,  that  he  was  lost  and  his  prospects  ruined,  and  that  his  life 
had  been  wasted  and  a  failure,  and  that  he  had  not  done  his  duty  by  his 
profession,  or  his  wife,  or  his  children.  At  those  times,  too,  his  in- 
tellectual processes  would  be  slow  and  torpid,  his  power  of  attention 
weakened,  and  the  arrival  at  any  conclusion  impossible  to  him  from  any 
data  whatever.  When  he  consulted  me  in  one  of  those  attacks  I  recom- 
mended absolute  rest,  a  sea  voyage,  almost  no  company,  plenty  of  easily 
digested  but  fattening  diet,  some  good  claret,  and  animal  food  only  once 
a  day.  I  told  him  he  might  live  on  bread,  butter,  milk,  eggs,  fish,  and 
fresh  vegetables  if  they  agreed  with  him  and  he  felt  that  they  digested 
well.  A  tonic  and  aid  to  digestion,  in  the  shape  of  quinine  and  nitro- 
muriatic  acid,  was  all  the  medicine  I  gave  him.  I  did  not  think  he 
needed  stimulating  nerve  tonics,  and  warned  him  against  opium,  which 
some  one  had  recommended,  as  against  his  worst  enemy.  I  told  him  to 
live  out  in  the  fresh  air  as  being  nature's  great  sleep  producer,  appetizer, 
and  tonic.  I  counselled  him  against  any  expenditure  of  nerve  energy 
whatsoever,  either  in  seeing  company,  travelling  too  fast,  walking  or 


STATES    OF    MENTAL    DEPRESSION.  59 

talking,  in  short,  he  was  to  take  mental,  affective,  motor,  and  sexual  rest. 
I  warned  his  friends  against  the  common  delusion  that  a  man  in  that 
state  needed  to  be  "-cheered  up"  specially.  My  experience  has  been 
that  such  cheering  up  is  a  natural  process  that  will  come  of  itself  when 
the  brain  attains  its  normal  trophic  and  energizing  power.  I  have  seen 
many  patients  still  further  exhausted  by  the  violent  and  continuous  efforts 
made  to  cheer  them  up. 

I  gave  my  opinion  as  to  the  prognosis  that  he  would  probably  get  over 
each  attack  as  they  came  on  him,  but  that  he  should  be  extraordinarily 
careful  when  he  came  towards  old  age,  and  said  he  would  probably  be  an 
old  man  before  his  time. 

As  to  prophylaxis,  I  recommended  him,  when  he  got  better,  to  do  his 
work  with  great  system  and  order,  cutting  up  his  day,  like  the  face  of  a 
chess-board,  into  regular  divisions,  and  filling  in  each  with  regular  work, 
or  recreation,  or  rest.  I  told  him  to  weigh  himself  every  month,  and 
whenever  he  found  he  had  lost  three  pounds  to  stop  work  and  take  a 
change  or  a  sea  voyage.  I  recommended  the  bromide  of  potassium  for 
sleeplessness,  in  twenty-five  grain  doses,  if  fresh  air  Avould  not  do. 

That  is  the  type  of  a  very  mild  case  of  simple  melancholia,  caused  by 
over  brain-work  in  a  person  predisposed  to  it  by  lieredity.  In  such  a 
case  it  seems  as  if  brain  ansemia  was  present,  the  morning  exacerbation 
after  the  physiological  sleep  anaemia  pointing  to  this,  relief  being  ob- 
tained by  anything  that  determined  more  blood  to  the  organ. 

As  an  example  of  simple  melancholia  with  partial  paralysis  of  volition, 
and  of  that  particular  kind  of  morbidness  which  consists  in  never 
"making  up  one's  mind,"  along  with  a  subtle  kind  of  morbid  introspec- 
tion and  morbid  magnification  of  small  things,  the  following  graphic 
case  of  A.  C  is  of  much  interest:  She  was  a  young  lady  who  had 
worked  far  too  hard  at  school,  and  so  had,  I  have  no  doubt,  produced 
chronic  hyperemia  of  her  brain  membranes,  and  impaired  nutrition  of 
her  convolutions,     I  quote  from  her  own  description  of  her  mental  state. 

"I  watch  every  action,  word,  and  thought,  constantly  questioning 
them,  accounting  for  them,  excusing  them,  or  deprecating  them.  Every 
day  I  rise  I  wish  to  be  happy  like  the  others,  I  will  not  torture  my 
brain.  It  is  a  sin  to  steal  my  own  happiness  and  that  of  others,  I 
reason,  resolve,  and  hope ;  but  the  greater  the  effort  to  be  free  the  greater 
the  struggle.  I  have  been  so  oppressed  with  this  unspeakable  distress 
that  I  feel  as  if  I  were  two  persons — the  one  tyrannically  demanding  to 
be  gratified,  the  other  protesting  and  pleading.  I  am  often  in  despaii', 
and  feel  my  life  a  burden.  At  night  I  am  glad  the  day  is  done;  in  the 
morning  I  am  in  terror  the  day  will  be  a  repetition  of  the  former.  The 
most  trivial  incident  will  occupy  my  mind ;  I  discuss  it  in  all  its  bearings, 
telling  myself  all  the  time  it  is  not  worthy  of  my  consideration.  Some 
one  speaks  to  me,  or  some  one  is  talking.  If  the  former,  I  answer  (often 
very  abstractedly)  with  the  feeling  that  there  is  something  in  my  mind; 
then  I  return  to  the  triviality.  If  I  have  forgotten  it  I  must  remember 
it,  and  then  with  a  distinct  effort  put  it  away  from  my  mind.  It  steals 
back.  I  tell  myself  that  I  have  already  discussed  it,  but  I  must  repeat 
the  whole  matter  to  myself,  and  that  with  no  ordinary  process  of  thought, 
I  seem  to  feel  a  strange  strain  on  my  memory,  and  again  I  have  to  use 


n 


60  STATES    OF    MENTAL    DEPRESSION". 

an  effort  to  banish  this  nothing.  Again  it  will  arise  and  be  dismissed; 
and  I  number  the  times  as  carefully  as  if  much  depended  on  it.  The 
efforts  to  dismiss  the  subject  cause  the  blood  to  rush  to  my  head,  the 
perspiration  to  break,  and  I  often  find  my  hands  clenched  in  the  struggle. 
All  through  this  I  can  bear  a  calm  exterior,  no  one  knowing  how  I  am 
tortured.  This  fret  goes  on  in  every  circumstance.  I  try  to  divert 
myself,  and  go  here  and  there,  seek  the  conversation  of  some  one,  seek 
solitude,  try  the  piano,  then  a  book,  until  I  feel  like  a  haunted  creature. 
This  strain  upon  my  mind  I  cannot  endure.  I  seem  paralyzed.  I  can- 
not perform  anything  I  wish  to  do,  though  I  spend  any  amount  of  energy 
in  fretting. 

"  To  one  whose  mind  is  healthy  thoughts  come  and  go  unnoticed,  with 
me  they  have  to  be  faced,  thought  about  in  a  peculiar  fashion,  and  then 
disposed  of  as  finished,  and  this  often  when  I  am  utterly  wearied  and  would 
be  at  peace;  but  the  call  is  imperative.  This  goes  on  to  the  hindrance 
of  all  natural  action.  If  I  were  told  the  staircase  was  on  fire  and  I  had 
only  a  minute  to  escape,  and  the  thought  arose — 'Have  they  sent  for 
fire  engines?  It  is  probable  the  man  who  has  the  key  is  at  hand.  Is 
the  man  a  careful  sort  of  person  ?  Will  the  key  be  hanging  on  a  peg  ? 
Am  I  thinking  rightly?  Perhaps  they  don't  lock  the  depot.'  My  foot 
would  be  lifted  to  go  down.  I  should  be  conscious  to  excitement  that  I 
was  losing  my  chance — but  I  should  be  unable  to  stir,  until  all  these 
absurdities  were  entertained  and  disposed  of.  In  the  most  critical 
moments  of  my  life,  when  I  ought  to  have  been  so  engrossed  as  to  leave 
no  room  for  any  secondary  thoughts,  I  have  been  oppressed  by  the 
inability  to  be  at  peace.  And  in  the  most  ordinary  circumstances  it  is 
all  the  same.  Let  me  instance  the  other  morning  I  went  to  walk.  The 
day  was  biting  cold,  but  I  was  unable  to  proceed  except  by  jerks.  Once 
I  got  arrested — my  feet  in  a  muddy  pool.  One  foot  was  lifted  to  go, 
knowing  that  it  was  not  good  to  be  standing  in  water,  but  there  I  was 
fast,  the  cause  of  detention  being  the  discussing  with  myself  the  reasons 
why  I  should  not  stand  in  that  pool." 

The  morbid  "watching  of  herself,"  as  she  calls  it,  is  a  very  common 
psychological  phenomenon.  The  morbid  doubting,  too,  and  inability  to 
make  up  her  mind  to  action,  are  also  common.  I  know  a  young  man  of 
a  most  neurotic  family,  whose  sister,  C.  E.,  was  insane  and  suffered  from 
the  variety  of  mania  that  I  shall  describe,  who  suffered  from  simple 
melancholia,  but  still  more  from  this  "insanity  of  doubt,"  for  he  would 
stop  half  an  hour  in  dressing  to  decide  which  stocking  to  put  on  first, 
and  has  been  known  to  stand  for  two  houi-s  where  three  roads  met,  trying 
to  decide  which  to  take.  If  hurried  or  forced  during  those  morbid 
periods  of  doubt,  he  suflers  intense  mental  pain,  and  is  inclined  to  resist 
dictation.  Such  cases  throAV  much  light  on  many  of  the  resistive  and 
apparently  "obstinate"  moods  of  the  insane,  who  are  too  much  affected 
intellectually  to  describe  their  subjective  sensations,  or  to  give  their 
reasons  for  their  conduct. 

To  return  to  A.  C,  whose  letter  I  have  quoted.  She  could  not  walk 
far,  had  palpitation  when  she  ran,  had  no  courage  to  ride,  had  much 
confusion  and  pain  at  vertex  of  head  after  reading  or  thinking  hard. 


STATES    OF    MENTAL    DEPRE3SI0X.  61 

She  was  fairly  nourished,  slept  well,  menstruation  was  regular,  and  she 
looked  a  sweet,  bright,  intelligent  girl. 

During  adolescence  she  had  suffered  much  from  neuralgia,  severe 
headaches,  depression  of  spirits,  and  a  few  attacks  of  hysteria,  and  had 
no  surplus  stock  of  nerve  energy  or  trophic  power.  She  had  used  up  in 
school-work  the  energy  that  ought  to  have  gone  to  build  up  her  brain 
and  body,  and  had  thus  caused  the  brain  hyperaemia  which  I  believed  to 
be  present.  I  prescribed  life  in  the  open  air,  no  reading,  no  work 
amongst  the  poor  (that  had  strained  her  by  over-sympathy  with  them),  to 
live  largely  on  non-stimulating  fattening  food,  to  take  bromide  and  iodide 
of  potassium  and  strychnine  meantime  till  she  could  get  to  Schwalbach 
and  take  the  baths  and  chalybeate  waters  there.  This  she  did,  and  im- 
proved greatly,  and  she  writes  me  lately:  "I  have  learned  to  have  many 
open  air  interests.  I  have  during  this  severe  winter  enjoyed  myself  in 
almost  boyish  enjoyments,  contrary  to  my  natural  bent.  I  am  an  indus- 
trious gardener,  and  an  enthusiast  in  poultry  keeping.  I  am  fond  of 
drawing  and  painting.  I  now  busy  myself  in  feminine  pursuits,  and  have 
a  most  pleasant  life ;  but  all  this  is  sometimes  spoiled  still  by  the  former 
misery  which  renders  all  the  occupations  an  effort.  But  I  never  give  in; 
and  one  looking  on  would  never  guess  that  anything  ailed  me." 

I  have  on  several  occasions  met  with  cases  of  this  type  in  women  of  a 
nervous  diathesis  or  heredity,  both  before  and  after  marriage,  in  which 
the  morbid  doubting  and  introspection  were  very  prominent  features. 

I  have  met  with  many  cases  very  similar  to  this,  but  each  one  with  its 
own  individual  features.  It  seems  to  me  no  diseases  are  so  individual- 
ized in  each  case  as  mental  diseases.  It  seems  as  if  the  brain  showed  its 
infinite  dominance  over  every  other  organ  by  the  extraordinary  variety 
in  its  derangements.  One  gentleman,  A.  D.,  set.  50,  I  used  to  attend, 
had  all  the  features  of  the  one  I  have  described,  with  the  addition  of  a 
distinct  delusion,  viz.,  that  syphilis  which  he  had  had  in  youth  had  been 
transmitted  to  his  children.  There  they  were,  before  him,  as  plump  and 
healthy,  and  rosy  as  they  could  be,  and  yet  he  would  say  they  looked 
like  death  and  disease,  and  would  remorsefully  point  to  almost  invisible 
pimples  or  skin  marks,  and  affirm  they  were  evidence  of  his  belief.  He 
could  not  be  got  to  go  to  business,  though  quite  capable  of  doing  it  other- 
wise, and  lost  his  appointment  thereby.  Nothing  would  induce  him  to 
walk  out  alone.  In  his  case  his  bodily  health  was  really  very  good. 
He  has  never  quite  recovered  from  his  second  attack  in  which  I  saw  him. 

Such  attacks  of  simple  melancholia  sometimes  occur  in  young  persons 
at  puberty  or  adolescence.  In  such  cases  there  is  always  a  strong  hei'edi- 
tary  tendency  towards  the  neuroses  if  not  to  mental  disease.  I  was 
asked  to  see  A.  E.,  a  girl  of  15,  some  of  whose  mother's  family  had  been 
insane,  who  was  clever  and  studious,  though  at  one  time  wild  and  mis- 
managed, who,  after  hearing  a  sermon  one  Sunday,  became  very  de- 
pressed, insisted  on  praying  with  the  other  girls  in  the  school,  and  was  a 
little  excited  and  demonstrative.  The  great  feature  of  her  case  was  one 
which,  in  different  forms,  is  very  common  in  young  brains  that  are  sub- 
ject to  the  psychoses,  viz.,  a  sort  of  automatic,  rhythmical,  and  emo- 
tional movement.  She  became  what  she  and  those  about  her  called 
"agonized"  when  lefl  alone,  that  is,  she  would  get  into  a  state  of  de- 


62  STATES    OF    MENTAL    DEPRESSION. 

pressed  brain  action ;  kneeling,  uttering  over  and  over  again  rhythmical 
expressions  of  prayer,  swaying  her  body  backwards  and  forwards,  and 
wringing  her  hands  at  intervals.  When  with  others,  or  at  her  lessons, 
she  would  appear  to  be  quite  well,  but  reserved  and  shy,  and  could  not 
learn  her  lessons  so  well  as  before,  and  had  no  tendency  to  romp.  She 
was  becoming  paler  and  thinner.  She  ate  well.  She  had  never  men- 
struated. Her  intelligence,  when  I  saw  her,  was  normal ;  and  she  said 
she  was  quite  well,  and  would  admit  no  depression.  She  said  she  had 
headache  in  one  temple,  and  felt  her  back  weak.  She  admitted,  on  being 
pressed,  that  several  things  troubled  her,  but  that  they  were  not  of  much 
consequence,  and  that  she  was  "nervous"  and  could  not  control  herself 
at  times.  She  said  she  could  not  take  much  interest  in  her  lessons,  or 
play,  or  anything  else.  I  sent  her  at  once  to  the  country,  to  ride,  walk, 
live  in  the  open  air,  to  take  aloes,  iron,  and  quinine,  to  read  little,  not 
to  go  to  church  for  a  short  time,  to  give  up  coffee  and  tea,  and  animal 
food,  but  take  milk  and  eggs  ad  libitum..  At  first,  for  a  month  or  two, 
she  used  to  feel  depressed,  slightly  agitated  before  people,  but  then  soon 
got  girlish,  romping,  and  quite  well.  After  a  tour  in  Switzerland  she 
was  fat,  cheerful,  and  vigorous,  with  no  undue  religious  emotionalism. 
She  menstruated  soon.  If  one  had  the  guidance  of  such  a  life,  much,  I 
think,  might  be  done  by  prophylaxis  to  ward  off"  attacks  of  the  neuroses. 
But  one  great  contingency  it  is  most  difficult  to  know  how  to  meet,  viz., 
marriage.  If  such  a  woman  marries,  she  runs  innumerable  risks  in 
pregnancy,  childbirth,  and  lactation  ;  and  she  may  have  weakly  children ; 
if  she  remains  single,  she  runs  nearly  as  many  in  unused  functions,  hys- 
teria, unsatisfied  cravings,  objectless  emotion,  and  want  of  natural  in- 
terests in  life.  For  herself  she  would  get  more  happiness  in  life  by  mar- 
rying; for  the  world  it  is  better  that  she  should  not.  But  prophylaxis 
in  mode  of  living,  attention  to  keep  the  body  nutrition  at  all  times  up  to 
the  highest  mark,  and  early  treatment  of  the  beginnings  of  the  evil 
would,  I  am  sure,  greatly  ward  off"  the  risks  of  another  attack.  I  need 
hardly  say  that  the  "  cause  "  assigned — viz.,  the  sermon  she  heard — had 
in  reality  less  to  do  with  the  disease  than  the  brain  she  took  to  church, 
predisposed  by  heredity,  exhausted  by  study,  and  the  unnatural  life  at  a 
boarding-school,  starved  of  fresh  air,  and  rendered  unstable  by  the  physi- 
ological crisis  of  commencing  menstruation.  And  here  I  would  say, 
once  for  all,  about  unusual  religious  services,  exciting  preaching,  and 
"revival  meetings,"  that,  as  a  physician,  I  have  no  objection  to  them  at 
all,  rather  the  contrary,  but  I  think  they  are  only  suited  to  stolid  healthy 
brains,  and  should  on  no  account  be  attended  by  persons  with  weak 
heads,  excitable  dispositions,  and  neurotic  constitutions. 

The  immense  variety  that  the  combination  of  diff"erent  mental  or  ner- 
vous symptoms  is  capable  of  producing,  comes  out  in  this  the  simplest  of 
all  mental  ailments.  In  some  cases  the  mental  pain  is,  as  it  were,  nega- 
tive rather  than  positive,  in  others  there  is  a  simple  blunting  of  the  emo- 
tions with  a  tinge  of  depression  ;  in  others,  again,  the  normal  gayety  dis- 
appears, in  others  there  is  a  paralysis  of  energy,  in  others  a  sudden 
ceasing  to  care  anything  about  the  usual  interests  of  life,  in  others  a 
natural  suspiciousness  of  temperament  becomes  morbid  and  causes  mental 
pain,  in  others  a  natural  diffidence  of  disposition  increases  so  as  to  be- 


STATES    OF    MENTAL    DEPRESSION.  63 

come  a  disease  and  to  cause  intense  unhappiness,  and  in  others  it  is  a 
mere  tedium  vitce.  It  Avould  swell  the  bulk  of  this  lecture  to  utterly  im- 
possible proportions  were  I  to  give  cases  illustrative  of  all  these  condi- 
tions, but,  to  show  the  ordinary  types,  I  give  one  or  two.  I  was  once 
consulted  about  a  lady,  A.  F.,  about  40  years  of  age;  Avho  was  said  to 
have  had  a  similar  attack  some  years  before  and  to  have  recovered.  She 
had  given  up  her  business,  and  had,  therefore,  no  serious  interests  in  life. 
She  had  been  for  some  months  ill.  AVhen  Avell,  she  had  been  a  clever 
active  Avoman  in  body  and  mind,  had  conducted  a  business  enthusiasti- 
cally and  profitably,  was  sociable  and  a  favorite  with  her  friends.  When 
I  saw  her  she  had  little  mental  pain,  but  she  had  no  mental  or  bodily 
pleasure.  She  had  no  energy — no  interest  in  anything.  She  had  no 
delusion,  except  an  unreasoning  belief  that  she  could  not  get  better  could 
be  considered  one.  She  was  utterly  careless  about  her  dress,  or  appear- 
ance, or  cleanliness.  She  was  obstinate  about  some  things ;  she  cared 
for  nothing  or  nobody.  The  only  thing  in  whiqh  she  took  any  interest 
was  talking  about  her  symptoms.  Her  memory  was  good,  her  reasoning 
power  was  good.  She  was  thin  and  flabby.  She  would  do  nothing  she 
was  told.     She  recovered  after  about  three  years. 

I  have  seen  many  cases  where  the  mental  symptom  of  depression  was 
so  subsidiary  to  general  nervous  prostration,  incapacity  to  walk,  work,  to 
digest  food,  or  to  fatten,  and  so  Avas  overlooked.  I  knew  one  case,  A. 
G.,  Avhere,  as  the  result  of  many  causes  of  nervous  exhaustion,  along 
with  mild  mental  depression,  indigestion,  and  the  most  distressing  weak- 
ness, the  cai-diac  innervation  Avas  so  Aveak  that  the  recumbent  position 
had  to  be  kept  almost  constantly  for  a  time  for  fear  of  syncope.  She 
recovered  in  tAvo  years  under  tonics,  changes  of  scene,  and  a  warm 
climate.  Many  of  these  cases  are  of  the  same  essential  nature  as  typical 
mild  melancholia.  American  medical  authors  have  much  to  say  about 
nervous  exhaustion  and  prostration — the  Neurasthenia  of  Beard.  For 
the  cure  of  some  of  the  cases  a  plan  of  treatment  has  been  adopted,  the 
most  irrational  that  Avas  ever  conceived  by  the  medical  mind.  It  is  that 
of  the  massage^  or  making  the  muscles  contract  and  the  blood  circulate 
faster  by  rapid  percussion,  squeezing  and  riibbing  the  body  all  over  every 
day,  while  the  patient  is  confined  to  bed,  instead  of  Avalking  in  the  fresh 
air.  Such  a  plan  may  suit  a  fcAV  exceptional  cases  with  weak  hearts, 
but  to  apply  it  to  many  cases  seems  to  me  utterly  absurd.  It  seems  as 
if  the  air  and  climate,  and  the  mode  of  life  and  education  in  some  parts 
of  America  Avere  so  stimulating,  that  the  brain  there  sometimes  exhausted 
both  its  OAvn  trophic  and  energizing  poAver,  and  paid  the  penalty  by  pro- 
longed periods  of  "  Neurasthenia."  The  natural  cure  would  seem  change 
to  a  more  sleepy  climate. 

There  are  some  instances  where  the  higher  affective  life  is  paralyzed, 
while  the  lower  appetites  and  propensities  are  left  intact,  if  not  actually 
increased.  A  melancholic  patient  once  said  to  me,  "  I  canna  think, 
canna  do  anything,  canna  care  for  anything — wife  or  children,  or  any- 
thing at  all,  but  meat,  meat !  If  they  were  all  lying  dead  I  would  not 
care  a  curse  if  I  got  meat." 

In  certain  other  cases  there  are  extraordinary  combinations  of  mental 


64  STATES    OF    MENTAL    DEPKESSION. 

symptoms  along  with  the  mental  depression,  of  which  this  is  an  example, 
with  a  morbid  fear  of  forgetting  names  and  words  : 

A.  H.,  set.  64.  Disposition  cheerful.  Temperament  sanguine,  but 
not  a  "nervous"  man  at  all.  Habits  most  industrious,  steady,  and  ac- 
curate, but  somewhat  sedentary.  A  clever  and  intelligent  business  man. 
Mother  died  of  some  brain  affection,  without  distinct  mental  disease. 
The  only  other  predisposing  cause  was  his  time  of  life — the  climacteric. 
The  exciting  cause  of  the  aggravation  of  the  mental  state  which  neces- 
sitated his  coming  to  this  asylum  was  the  death  of  a  sister.  His  present 
attack  has  been  of  gradual  onset,  beginning  in  a  very  mild  way  some 
years  back,  getting  worse,  and  only  assuming  a  form  that  could  be 
reckoned  technical  insanity  four  months  ago.  He  began  by  being  fan- 
ciful and  disinclined  for  bodily  or  mental  exertion ;  in  fact,  a  kind  of 
morbid  laziness  came  over  him.  Laziness  is  more  often  a  real  disease 
than  is  commonly  imagined ;  it  simply  means,  in  those  cases,  diminished 
evolution  of  nerve  energy.  He  gradually  and  steadily  got  worse,  falling 
more  under  the  influence  of  his  morbid  fancies.  They  produced  insane 
conduct  five  months  ago,  which  showed  itself  as  morbid  restlessness, 
shouting,  and  acting  on  his  unfounded  suspicions.  He  suspected  that 
people  were  plotting  against  him,  that  there  was  a  society  in  the  next 
street,  the  members  of  which  got  into  his  room  at  night  and  stole  his 
clothes  and  watch.  He  got  into  silly  conservative  habits,  so  that  the 
slightest  new  Avay  of  the  house  was  most  disagreeable  to  him.  He  could 
not  be  got  to  go  out  and  walk,  or  to  attempt  business.  Once  he  threatened 
to  commit  suicide  with  a  razor,  but  seemed  to  have  no  serious  intention 
to  hurt  himself.  His  memory  became  impaired  in  regard  to  some  things, 
and  he  thought  it  worse  than  it  really  was.  His  affection  for  his  rela- 
tions diminished,  and  he  lost  his  social  instincts. 

On  his  admission  into  the  asylum  he  was  mildly  depressed.  His 
morbid  suspicions  seemed  not  only  to  be  a  symptom  of  the  disease,  but 
also  a  cause  of  depression.  He  was  restless,  fidgety,  easily  startled,  and 
perversely  irritable.  There  was  some  limited  enfeeblement  of  mind  in 
regard  to  certain  things,  e.  g.,  inability  to  identify  familiar  persons  and 
places,  or  to  recall  events  at  wfll,  he  had  groundless  fears,  and  his  manner 
was  hesitating.  His  memory,  in  regard  to  most  matters,  was  unimpaired, 
but  in  regard  to  names  it  was  most  peculiar,  for  he  had  a  feeling,  almost 
amounting  to  terror,  that  he  would  forget  some  familiar  name.  His  voli- 
tion was  quite  weak  as  regards  its  positive  action,  but  there  was  a  good 
deal  of  obstinacy.  In  appearance  he  was  fairly  nourished,  but  flabby 
and  slightly  paretic  looking.  His  left  shoulder  fell  a  little.  His  left 
side  seemed  a  little  weaker,  but  about  this  there  was  a  doubt,  and  his 
articulation  was  rather  indistinct.  He  said  he  had  a  difficulty  of  swallow- 
ing. His  tongue  seemed  to  go  slightly  to  the  right  side  when  put  out. 
Sensory  power  was  somewhat  dulled,  and  reflexes  were  normal.  His 
tongue  was  dry  and  bare  in  the  centre.  Pulse  72,  and  weak.  Tem- 
perature 96.8°,  being  generally  under  this  in  the  morning,  though  in  the 
evening  it  was  sometimes  97°,  the  average  evening  temperature  being 
96.6°.  This  low  temperature  was  evidently  a  part  of  his  disease.  He 
was  put  on  strychnine  and  iron,  nourishing  diet,  and  as  much  fresh  air 
as  he  could  take,  while  every  effort  was  made  to  amuse  and  occupy  him. 


STATES    OF    MENTAL    DEPRESSION.  65 

He  improved  in  pith  and  strength,  but  the  apparent  slight  hemi-paresis 
often  passed  to  the  right  side.  Mentally  he  improved,  too,  by  being 
kept  in  a  steady  routine  of  physiological  living.  Anything  out  of  this 
routine  annoyed  him  exceedingly,  and  put  him  much  about.  After  a 
time  his  mental  depression  centred  round  his  fear  of  not  "  remembering 
names."  In  reality,  he  would  remember  them  pretty  well,  but  he  would 
get  most  unhappy,  and  sometimes  excited,  and  most  irritable  through  the 
morbid  fear  he  would  forget  them.  In  reading  the  newspaper,  he  would 
mark  certain  names  down  on  paper  lest  he  should  forget  them.  He 
would  come  up  to  me  and  ask  in  the  most  earnest  tone,  as  if  his  life  de- 
pended on  the  answer — "  Doctor,  can  you  tell  me  the  name  of  that  burn 
in  Fife  I  fished  in  in  1850  ?  I  can't  get  it,  and  it  makes  me  miserable." 
At  times  it  seemed  as  if  he  had  a  dreamy  mental  vision  of  great  rows  of 
long  botanical  and  topographical  names,  whose  exact  spelling  and  pro- 
nunciation he  could  not  make  out,  and  that  this  made  him  utterly  miser- 
able. He  got  very  stout  after  about  six  months,  and  went  (much  against 
his  will)  to  the  asylum  seaside  house,  where  he  still  further  improved, 
and  then  unwillingly  went  home,  where  he  lives  a  mentally  depressed, 
peculiar  life,  fearing  the  loss  of  words  and  names  still.  If  his  newspaper 
does  not  come  at  the  proper  moment,  or  if  a  relative  sits  down  on  an 
unusual  chair,  he  is  very  miserable.  The  things  that  he  fears,  and  that 
put  him  about,  are  trivial  unaccustomed  things,  and  the  greater  things 
of  liis  life  do  not  aiFect  him  at  all.  A  keen,  sharp,  business  man,  he 
cares  nothing  now  for  money  or  business.  He  shows  a  mild  dementia, 
along  Avith  a  mild  melancholia.  Every  effort  is  made  to  keep  up  his 
bodily  health  and  stoutness  by  good  food,  fresh  air,  and  nerve  tonics,  and 
though  he  will  never  recover,  he  enjoys  some  happiness.  He  can  origi- 
nate nothing,  and  new  events  annoy  him.  Any  attempt  to  argue  with 
him,  or  try  and  convince  him  of  the  absurdity  of  his  whims,  always 
makes  him  worse,  for  his  reasoning  power  is  greatly  paralyzed.  One 
might  as  reasonably  try  and  convince  a  man  with  locomotor  ataxia  that 
he  should  not  lift  his  leg  so  high  and  should  put  it  down  more  steadily. 
His  brain  is  clearly  anaemic,  and  partly  atrophied,  and  energizes  feebly. 
Tiie  things  that  in  an  ordinary  man  would  cause  just  a  moment's  annoy- 
ance, are  to  him  very  great  things,  from  his  weakness  of  reasoning  power, 
paralysis  of  volition,  and  emotional  hyperaesthesia.  Many  of  his  peculi- 
arities result  from  his  old  methodical  habits  remaining  in  an  insane  and 
grotesque  form.  He  has  been  three  years  ill,  and  the  slightly  paralytic 
symptoms  are  proof  to  me  that  he  has  some  brain  degeneration,  probably 
combined  with  a  good  deal  of  convolutional  atrophy. 

In  the  cases  I  have  referred  to,  the  condition  of  simple  melancholia 
has  been  the  mental  disease  from  beginning  to  end,  but  very  often  it  is 
merely  a  stage  in  the  clinical  history,  and  the  case  soon  assumes  a  deeper 
and  different  form  of  depression,  or  in  some  cases  it  passes  into  mania. 
It  must  be  clearly  understood  that  the  kinds  of  melancholia  I  am  describ- 
ing are  mere  varieties,  and  have  not  the  characters  of  real  diseases  or 
pathological  entities.  I  am  taking  this  symptom  of .  depression  of  mind 
and  describing  it  as  melancholia ;  and  I  am  taking  this  depression  in 
certain  degrees  and  with  certain  marked  characters  or  accompaniments 
in  different  patients,  and  describing  such  cases  as  I  would  the  varieties 

5 


66  STATES    OF    MENTAI.    UEPEESSION. 

of  a  species  of  plant,  for  convenience  and  clearness.  A  case  may  exhibit 
one  form  of  depression  of  mind  at  one  time  and  another  at  another. 

Simple  melancholia  sometimes  becomes  chronic,  of  which  this  was  an 
example,  having  depression,  but  great  self-control  before  strangers,  intel- 
lectual vigor,  morbid  sensitiveness  as  to  people  knowing  about  her  illness, 
want  of  real  enjoyment  of  food,  but  eating  plenty,  grimacing  and  swear- 
ing in  secret ;  almost  tearless  weeping,  wringing  her  hands,  and  nervous 
jerkings : 

A.  J.,  set.  63.  No  children.  Temperament  melancholic,  and  diathesis 
nervous,  but  disposition  lively,  happy,  and  very  energetic ;  very  intelli- 
gent. Habits  active  ;  well  educated  and  well  bred.  For  four  years  she 
had  been  depressed,  unsocial,  morbidly  shy,  and  in  great  dread  lest  her 
friends  should  know  there  was  anything  wrong.  Cannot  make  up  her 
mind  about  anything,  and  to  any  new  proposal  whatever  is  always  averse ; 
changed  in  ways;  not  so  particular  as  to  dress  and  cleanliness  as  in 
health  (this  is  very  common  in  similar  cases),  and  more  penurious  (also 
common).  When  she  sees  strangers  or  friends  she  can  talk  and  behave 
very  well,  and  seems  almost  to  enjoy  it.  Always  objects  to  going  any- 
where, but  does  not  like  to  be  left  at  home.  Has  no  power  of  coming  to 
any  resolution,  but  much  of  passive  resistance  and  objection.  Conceives 
very  strong  dislikes,  reads  all  day  and  very  quickly,  but  will  not  sew,  or 
knit,  or  play ;  very  acute  and  observant ;  very  sure  she  will  never  get 
well.  As  she  sits  and  talks  to  one,  she  never  looks  one  in  the  face,  and 
fidgets  and  jerks,  and  sometimes  makes  faces.  When  alone  she  swears 
and  uses  most  abominable  language,  this  being  of  course  utterly  foreign 
to  her  real  nature  and  former  habits.  She  says  she  cannot  help  it,  and 
deplores  it — a  common  symptom  in  such  cases.  She  says  she  never 
sleeps,  but  this  is  not  true,  though  she  sleeps  badly  at  times  and  walks 
about  the  room.  I  have  another  case,  just  like  this,  who  "longs  for 
sleep,"  and  feels  drowsy  and  sleepy  often,  but  cannot  sleep  well  at  night, 
though  she  takes  a  nap  for  an  hour  every  day  after  dinner.  A.  J.  looks 
fairly  well,  but  is  worn  looking,  and  though  muscular  has  fallen  off  in 
weight  and  fatness.  She  had  an  eczematous  skin  irritation.  Bowels 
costive,  tongue  furred. 

For  treatment,  I  put  this  lady  on  very  many  things.  Opium  did 
harm,  and  so  did  the  vegetable  narcotics,  all  but  cannabis  Indica  in  fif- 
teen drop  doses,  which  I  gave  with  good  result  when  she  was  unusually 
restless  and  sleepless,  combined  with  thirty  grains  of  the  bromide  of  potas- 
sium. I  gave  her  in  succession  arsenic,  strychnine,  iron,  quinine,  the 
mineral  acids,  the  hypophosphites,  salt  baths,  fresh  air,  and  walking  ad 
libitum,  cod-liver  oil,  maltine,  employment,  milk,  fruit,  fresh  vegetables, 
and  farinaceous  and  fish  diet,  largely  ringing  the  changes  on  the  tonic 
medicines,  with  Friedrichshall  water  every  other  morning  for  the  bowels. 
The  course  of  arsenic  did  much  good,  being  followed  by  an  increase  of 
body  weight.  Though  she  did  not  get  well,  yet  undoubtedly  she  got 
fatter  and  happier  and  more  comfortable  to  do  with,  and  remains  so  now 
at  the  end  of  three  years.  It  is  a  mistake  to  suppose  that  such  cases  do 
not  need  tonic  treatment,  or  that  it  does  no  good.  Every  pound  of  body 
weight  gained  means  a  gain  in  nervous  and  mental  tone.    I  recommended 


STATES    OF    MENTAL    DEPEESSION.  67 

quiet  places  among  friends  and  not  much  travelling  about,  which  tended 
to  excite  her.  I  was  always  in  the  fear  of  her  passing  into  mild  exalta- 
tion, and  becoming  a  case  of  folie  eirculaire.  I  have  seen  strychnine, 
pushed  too  far  in  such  a  case,  decidedly  tend  towards  excitement.  This 
lady,  I  need  scarcely  say,  had  sought  (or  her  friends  had  sought  for  her) 
the  advice  of  many  physicians.  I  have  seen  such  a  case  get  quite  well, 
the  mental  pain  passing  quite  away  after  six  years.  This  case  leads 
naturally  to  the  next  variety  of  melancholia,  the  hypochondriacal,  having 
many  of  its  characters. 

Simple  melancholia  is  in  most  cases  curable ;  it  does  not  commonly 
require  treatment  in  an  asylum,  when  the  means  of  the  patient  admit  of 
suitable  attendance,  change,  and  treatment  elsewhere;  it  never  kills 
directly  by  exhaustion,  and  seldom  ends  in  dementia.  The  exceptions  to 
its  curability  occur  in  the  very  advanced  periods  of  life  when  the  brain 
is  retrogressing  or  degenerating,  or  where  it  occurs  as  an  accompaniment 
of  organic  brain  disease,  and  this  is  not  uncommon  when  there  is  a  strong 
neurotic  heredity  as  Avell  as  such  disease. 

Simple  depression  frequently  precedes  other  forms  of  mental  disease 
than  melancholia,  some  authorities  going  the  length  of  saying  that  it  is, 
the  necessary  prelude  to  all  kinds  of  insanity  whatever.  My  experience; 
is  that  it  is  not  the  necessary  prelude  to  mania  or  to  general  paralysis,; 
but  that  it  is  a  very  frequent  one  indeed. 

Hypochondriacal  Melancholia. — The  next  variety  of  melancholia 
is  a  rather  Avell-marked  one.  In  seriousness  it  exceeds  the  simple  form. 
It  is  further  away  from  mental  health,  psychologically  and  bodily.  The 
symptoms  are  more  decided  and  positive.  Along  with  the  aifective  de- 
rangement there  is  more  judging  aberration,  and  less  inhibition  over 
morbid  speech  and  conduct,  whilst  the  radical  instincts  and  habits  of  life 
are  not  aifected,  nor  is  the  self-control  so  lost,  as  they  are  in  the  severer 
varieties  of  the  disease.  The  mental  pain  has  a  certain  superficialness 
and  want  of  intensity,  and  the  cause  of  it  is  always  stated  by  the  patient 
to  be  diseases  or  disorder  of  the  bodily  organs  that  are  not  real,  or,  if 
real,  are  exaggerated  out  of  all  proportion  to  their  real  severity  in  the 
patient's  mind.  As  simple  melancholia  has  a  sane  initial  period,  and 
many  cases  are  never  legally  or  technically  insane  at  all,  so  hypochon- 
driacal melancholia  has  generally  a  sane  stage  and  a  sane  twin  brother; 
called  hypochondriasis,  Avhicli  is  usually  so  lightly  thought  of,  and  so. 
misunderstood,  as  to  be  for  the  most  part  thought  a  subject  of  laughter 
to  the  patient's  friends,  and  is  always  popularly  talked  of  as  being  a  state 
that  the  patient  has  got  into  through  his  own  fault,  and  could  get  out  of 
by  the  exercise  of  his  own  volition.  In  hypochondriacal  melancholia  a 
sense  of  ill-being  is  substituted  for  the  healthy  pleasure  of  living,  but  the 
ill-being  is  localized  in  some  organ  or  function  of  the  body.  The  pa- 
tient's depressed  feelings  all  centre  round  himself,  his  health,  or  the  per- 
formance of  his  bodily  or  mental  functions.  He  is  all  out  of  sorts,  he 
cannot  digest  his  food,  his  bowels  will  never  act,  his  kidneys  or  liver  are 
wrong,  he  has  no  stomach,  his  heart  is  weak,  and  he  asks  you  to  feel  his 
pulse,  which  is  just  going  to  stop  beating.  He  is  paralyzed,  and  will  not 
move  a  limb  till  he  forgets  his  fancy  for  a  moment ;  he  cannot  think , 
because  his  brain  is  made  of  lead  ;  he  is  made  of  glass,  and  will  break  if 


68  STATES    OF    MENTAL    DEPRESSION. 

roughly  handled.  There  are  no  limits  to  the  fancies  of  the  hypochon- 
driac or  the  hypochondriacal  melancholic.  The  way  we  distinguish  them 
— the  sane  from  the  insane  hypochondriac — is  this :  a  man  may  have 
any  conceivably  absurd  fancy  about  himself,  but  if  he  can  do  his  Avork  in 
the  world,  and  does  no  harm  to  himself,  and  has  a  fair  amount  of  self- 
control  ;  if  he  can  pick  himself  up  mentally  and  in  conduct  at  will,  and 
has  the  power  to  stop  talking  of  his  fancies  when  he  wishes,  even  though 
he  revels  in  the  descriptions  of  his  own  evacuations,  consults  all  the  doc- 
tors he  can  afford  to  pay  or  who  will  give  him  advice  without  pay,  and 
swallows  all  the  physic  he  can  afford  to  buy,  we  call  him  merely  a  hypo- 
chondriac ;  but  if  he  has  real  and  intense  mental  depression  that  he  can- 
not throw  off,  if  he  loses  his  self-control,  outrages  decency  openly,  prac- 
tises things  that  will  soon  end  his  days,  or  threatens  to  take  away  his 
own  life,  and  cannot  at  will  withdraw  his  mind  and  speech  from  his  delu- 
sion, then  we  call  him  a  melancholic  of  the  hypochondriacal  type,  and, 
if  necessary,  put  him  under  restraint.  But,  as  you  see,  there  is  no  line 
of  demarcation.  The  one  condition  is  often  the  first  stage  of  the  other. 
From  a  physiological  point  of  view  the  afferent  impressions  from  the 
organ  implicated  in  the  delusion  sent  up  to  the  brain  are  unpleasant, 
instead  of,  as  they  should  be,  pleasant.  The  secondary  cause  may  be 
real  peripheral  disorder.  A  man's  liver  may  not  be  working  well,  and 
causing  him  uneasiness,  or  his  stomach  may  not  be  doing  its  work  well, 
or  his  bowels  may  be  costive  (they  usually  are),  or  he  may  have  actual 
disease  in  the  part  that  he  says  is  wrong,  but  none  of  these  things  would 
cause  the  mental  phenomena  of  hypochondria  if  the  man's  brain  convo- 
lutions were  working  healthily,  therefore  the  real  cause  must  be  referred 
to  the  brain. 

The  following  was  a  case  of  hypochondriacal  melancholia  of  short 
duration : 

A.  K.,  set.  67,  unmarried.  Disposition  eccentric,  suspicious,  obstinate, 
and  unsocial.  Habits  sober,  but  not  continuously  industrious.  Has  had 
three  previous  attacks,  all  of  melancholia  of  a  hypochondriacal  character, 
treated  in  an  asylum.  No  ascertained  heredity  towards  the  neuroses. 
It  was  said  that  he  had  a  fall  on  his  head  when  he  was  ten  years  old, 
and  had  never  been  right  since,  but  I  attached  no  importance  to  this 
story.  The  exciting  cause  of  his  attack  was  said  to  be  masturbation,  but 
whether  this  was  a  cause  or  a  symptom  I  could  not  clearly  make  out. 
He  was  said  to  have  become  depressed  three  months  ago,  to  have  had 
suicidal  feelings,  to  which  he  gave  loud  expression,  to  have  lost  his  self- 
confidence  ;  and  he  became  perfectly  helpless  and  sleepless,  according  to 
his  own  account.  He  has  eaten  voraciously  all  the  time,  and  has  not 
fallen  off  in  looks  or  weight.  He  came  to  the  Asylum  voluntarily,  and 
considered  his  case  was  so  urgent  that  he  sent  for  me  out  of  church.  He 
said  he  felt  nervous  and  depressed,  and  was  afraid  every  minute  that  he 
would  lose  his  self-control.  He  was  full  of  fancies  as  to  the  bad  state  of 
his  own  bodily  health — that  his  bowels  were  very  costive,  and  that  he 
had  no  appetite  whatever.  He  wanted  to  be  most  carefully  examined  as 
to  the  state  of  his  lungs  and  heart,  and  more  especially  as  to  his  sexual 
organs.  He  had  a  real  chronic  enlargement  of  one  of  his  testicles,  and 
insisted  that  he  had  a  sore  on  his  penis,  the  existence  of  which  required 


STATES    OF    MENTAL    DEPRESSION.  69 

a  magnifying  glass  to  determine.  His  temperature,  pulse,  and  all  his 
organs  were  normal ;  he  was  well  nourished.  He  insisted  he  had  a 
serious  skin  eruption,  which  was  really  a  little  acne  on  his  hack.  He 
was  obtrusively  suicidal  in  his. expressions,  though  it  ought  to  have  been 
clear  to  him  that  if  he  was  prevented  from  putting  an  end  to  his  life  he 
would  soon  die  of  some  one  of  the  numerous  diseases  he  had.  He  re- 
mained in  this  state  for  about  two  months  and  a  half,  and  was  subjected 
to  rather  a  calm  but  strict  discipline  at  first.  He  was  most  acute  about 
money  matters,  most  fault-finding  as  to  his  food,  and  said  he  did  not 
sleep,  when  in  reality  he  snored  all  night.  He  was  inclined  to  be  dis- 
contented because  he  did  not  receive  that  amount  of  attention  which  his 
case  deserved.  I  never  laughed  at  him,  or  pooh-poohed  him,  nor  courted 
his  conversation,  but  put  him  on  tonics,  and  made  him  live  in  the  fresh 
air,  and  occupy  himself  pretty  constantly.  He  improved,  and  was  pretty 
nearly  recovered  in  three  months  from  his  admission,  in  another  six 
months  being  quite  lively  and  wanting  to  get  married. 

Here  is  another  case  of  a  deeper  and  more  serious  nature,  and  of  a 
longer  duration,  of  the  same  type,  the  cause  being  disappointment,  the 
sensations,  appetites,  and  propensities  being  changed ;  travel  aggravating 
the  symptoms,  Avhich  were  very  demonstrative,  with  suicidal  talk  and 
ludicrous  attempts ;  strychnine,  discipline,  and  fresh  air  having  a  very 
good  effect,  with  a  great  gain  in  weight  in  six  months : 

A.  L.,  aet.  38.  Temperament  melancholic.  Disposition  quiet, 
thoughtful,  gloomy,  energetic,  enthusiastic.  Habits  temperate ;  and 
very  hard  working.  Fond  of  active  work  rather  than  study.  Had  had 
a  previous  attack,  lasting  three  months,  of  the  same  character  as  that 
about  to  be  described,  but  not  so  severe,  and  treated  at  home.  Maternal 
uncle  and  aunt  eccentric,  if  not  insane.  The  existing  cause  of  the  present 
attack  was  a  disappointment.  It  began  by  simple  depression  and  in- 
capacity for  professional  work.  The  bodily  symptoms  were  at  first  sleep- 
lessness, and  then  a  curious  feeling  in  his  head  as  if  it  was  made  of  lead. 
His  thoughts  became  more  and  more  concentrated  on  his  health  and  the 
state  of  his  organs.  His  appetites  and  propensities  changed.  Instead 
of  being  very  fond  of  animal  food,  he  could  not  eat  it  at  all.  Instead  of 
having  the  nisus  gene7'ativus  keenly,  and  indulging  it  freely,  his  sexual 
appetite  was  gone.  He  had  had  non-specific  psoriasis  when  well,  and  it 
had  disappeared  (this  I  have  noticed  in  insane  patients  very  often).  He 
had  tried  the  usual  plan  of  travel  and  change  of  scene,  but  he  had  been 
the  worse  for  it,  as  often  occurs  in  melancholia.  There  is  scarcely  a 
point  on  which  I  have  so  much  difiiculty  in  the  early  treatment  of  melan- 
cholia as  whether  to  send  away  patients  to  travel  or  not ;  and  if  they  are 
to  go  from  home,  where  to  send  them  to.  Quick  travelling,  and  going 
to  many  places  in  a  short  time,  is  nearly  always  bad  for  a  patient.  Big 
noisy  hotels  and  an  exciting  life  are  also  nearly  always  bad ;  but  then 
one  must  have  change  of  some  sort,  breaking  off  old  associations,  and 
different  air,  and  scenery,  and  employment.  The  fact  is,  that  no  definite 
rules  can  be  laid  down  on  this  subject ;  but  there  are  a  few  considerations 
that  help  to  guide  one.  In  the  very  early  stages  of  the  disease,  when 
the  mental  pain  is  merely  incipient,  travel  abi'oad  often  does  good,  if  it  is 
done  in  a  systematic,  methodical  leisurely  way.     If  the  disease  has  ad- 


70  STATES    OF    MENTAL    DEPRESSION. 

vanced  so  far  that  the  power  of  attention  is  much  impaired,  then  a  quiet 
country  place,  where  there  are  few  visitors,  is  best.  If  the  bodily  con- 
dition is  very  weak  and  exhausted,  travelling  often  does  more  harm  than 
good.  If  there  are  delusions  of  suspicion  very  strong,  so  that  the 
patient  is  always  imagining  that  people  are  looking  at  him,  speaking 
about  him,  following  him,  then  the  quieter  he  is  kept  the  better. 

On  admission,  A.  L.  was  much  depressed,  and  very  demonstrative  in 
his  account  of  his  feelings  and  ailments.  He  could  not  read,  he  said,  or 
understand  what  he  read.  He  took  the  gloomiest  view  of  himself  and 
all  his  concerns;  was  very  suspicious,  thinking  that  people  were  watching 
him;  imagining  he  was  paralyzed  in  sensation,  and  partly  in  motion; 
that  he  had  no  appetite,  though  he  ate  voraciously,  and,  when  caught  in 
the  act,  saying  that  his  appetite  was  an  unreal,  unnatural  one.  He  said 
his  face  and  features  were  quite  changed,  and  he  wailfully  contrasted 
his  present  looks  with  his  former  appearance.  He  went  and  made  faces 
at  the  looking-glass,  and  said  he  could  not  help  it.  Said  his  natural 
affection  for  his  wife  and  children  was  gone,  and  his  senses  of  taste  and 
smell  were  dulled,  but  there  was  no  evidence  of  it.  He  said  his  brain 
felt  as  if  "made  of  lead,"  and  had  a  "contracted"  feeling.  He  was 
well  nourished  and  muscular,  and  all  his  organs  were  sound  but  his 
digestive  system,  which  was  clearly  out  of  order.  His  tongue  was  furred 
and  flabby,  taking  the  marks  of  the  teeth ;  his  bowels  were  costive ;  his 
pulse  was  68,  and  good;  his  morning  temperature  was  97°,  and  the 
evening  96.8°.  He  was  put  on  strychnine  in  one-thirty-second  grain 
doses  and  quinine,  and  he  affirmed  that  the  strychnine  did  him  good; 
that  he  felt  consciously  the  better  for  it;  that  it  pulled  him  up,  and 
enabled  him  to  exercise  more  inhibition  over  his  actions,  and  he  cer- 
tainly could  tell  when  it  was  omitted  from  the  mixture.  He  was  sent  to 
■walk  all  about  into  town  and  into  the  country,  and  though  he  often  re- 
ferred to  suicide,  it  was  assumed  in  his  case  that  there  was  no  real 
danger.  One  day  he  returned  from  a  walk  alone  in  a  most  excited  state. 
He  said  he  had  attempted  suicide,  and  disgraced  himself  for  life.  What 
was  he  to  do  ?  It  appeared  he  had  come  upon  a  flag-staff,  and  had 
taken  one  end  of  the  rope,  and  tied  it  around  his  neck,  and  had  then 
taken  the  other  in  his  hand,  and  attempted  to  hoist  himself  up  the  staff! 
But  there  was  no  mark.  Another  day  he  lay  down  in  a  ditch  with  a 
little  mud  at  the  bottom,  and  said  he  had  tried  to  drown  himself,  coming 
home  with  his  clothes  all  wet.  In  fact,  there  was  always  an  element  of  the 
ludicrous  in  his  misery  and  in  his  mode  of  expressing  it.  Regarding  the 
suicidal  efforts  and  expressions  of  hypochondriacal  melancholies,  though 
there  is  little  real  risk,  yet  there  is  some.  A  doctor  patient  of  mine 
once  took  a  poisonous  dose  of  morphia  (doctors  always  poison  themselves 
when  they  want  to  commit  suicide,  just  as  soldiers  always  shoot  them- 
selves), and  nearly  died.  When  A.  L.'s  mind  could  be  distracted,  and 
he  could  be  got  to  talk  of  anything  but  his  own  bad  feelings,  he  was 
rational,  intelligent,  and  his  memory  good,  this,  too,  being  characteristic 
of  such  patients.  He  got  various  tonics  along  with  the  strychnine — 
viz.,  iron,  arsenic,  vegetable  bitters,  the  phosphates — but  my  own  impres- 
sion is  that  the  strychnine  did  the  most  good. 

In  three  and  a  half  months  he  was  so  far  improved  that  he  believed 


STATES    OF    MENTAL    DEPRESSION.  71 

he  was  to  get  well  ultimately,  and  this  in  a  melancholy  ease  is  one  of  the 
first  and  one  of  the  surest  signs  of  commencing  recovery.  He  gained  a 
stone  in  weight.  He  could  divert  his  attention  more  easily  from  him- 
self.  His  mental  pain  was  less,  his  irritability  greater,  and  his  head 
felt  better.  He  lost  the  most  extravagant  of  his  delusions  first — viz., 
that  he  would  be  hanged  for  hurting  his  wife.  By  the  way,  he  had, 
what  I  have  often  noticed  in  such  cases,  exalted  ideas  of  the  beauty  and 
high  qualities  of  his  wife  and  his  children,  and  the  greatness  of  his  pre- 
vious position  and  prospects,  all  by  way  of  contrast  to  his  own  misery 
and  misdeeds.  In  six  months  he  was  quite  well,  and  soon  was  able 
for  hard  work,  which  he  did  as  well  as  ever,  being  able  to  make  a  large 
income. 

Now,  the  public  and  the  friends  of  patients  are  very  apt  indeed  to 
speak  of  such  cases  and  treat  them  as  if  it  was  all  the  patients'  fault,  as 
if  by  a  voluntary  effort  they  could  throw  off"  such  foolish  fancies.  One 
hears  even  doctors  talking  in  the  same  way.  They  do  not  appear  to 
understand  how  any  one  can  believe  such  manifest,  and  what  appears  to 
them  childish,  nonsense  about  the  state  of  the  hypochondriac's  health 
and  organs,  and  yet  be  reasonable  otherwise.  I  need  hardly  say  how 
absurd  such  a  view  of  the  matter  is.  The  two  cases  I  have  related  show 
how  such  a  condition  is  a  real  disease,  beginning,  running  its  course,  and 
ending  like  many  other  diseases.  The  physiological  view  to  take  of  such 
cases  is  that  in  them  we  have  the  brain-centres  that  preside  over  the 
great  organic  functions  of  alimentation  and  generation,  etc.,  disturbed. 
When  those  functions  are  normal,  and  the  brain  is  normal,  the  subjec- 
tive feeling  is  one  of  rest  and  satisfaction — one  of  organic  pleasure. 
When  the  functions  of  those  organs  are  interfered  with,  or  have  disease 
in  them,  we  have  a  feeling  of  organic  pain,  but  our  convolutions  being 
in  good  order,  we  do  not  put  a  wrong  interpretation  on  the  pain.  When 
the  brain-centres  that  preside  over  those  functions  are  affected  by  a  dis- 
ease-storm, then,  whether  there  is  disease  in  the  organs  or  not,  there  is 
often  sensible  disorder  or  lessening  of  function  (as  when  the  sexual  ap- 
petite was  paralyzed  in  A.  L.),  and  the  performance  of  function  gives 
no  sensible  organic  satisfaction.  If  the  intellectual  centres  are  also 
affected,  we  have  the  ill-being  and  pain  misinterpreted  and  attributed  to 
disease. 

All  cases  of  hypochondriacal  melancholia  do  not  recover  as  those  two 
did.  My  experience  has  been  that  this  kind  of  case,  when  it  occurs  at 
the  more  advanced  ages,  is  apt  to  be  permanent,  or  the  prelude  to  senile 
dementia.  I  had  a  medical  man  (A.  M.)  once  under  my  care  who  was 
sixty,  and  who  had  exactly  the  feelings  I  have  described,  but  who  had 
no  motor  excitement,  who  would  speak  in  the  calmest  manner  possible 
about  his  feelings.  He  said  that  eating,  though  he  had  an  appetite,  gave 
him  no  pleasure;  that  he  had  no  sense  of  repletion,  so  that  he  had  to 
stop,  not  because  he  felt  he  had  eaten  enough,  but  because  he  saw  he 
had  eaten  enough.  He  said  that  he  had  no  comfortable  satisfaction 
after  his  bowels  were  moved;  that  he  had  no  sexual  desire  or  power 
whatsoever,  which  was  true.  He  never  recovered,  and  he  never  could 
be  made  fat,  though  every  physiological  and  therapeutic  fiittener  was 
tried.     He  said  he  felt  all  the  time  as  if  he  had  a  paralysis  of  the  sym- 


72  STATES    OF    MENTAL    DEPRESSION. 

pathetic  in  his  abdomen.  It  was  he  who  tried  to  poison  himself  with 
morphia.  Certainly  the  cases  who  affirm  they  have  no  stomachs  nor 
gullets,  and  that  their  bowels  have  not  moved  for  years,  etc.,  must  have 
the  subjective  feeling  somewhat  the  same  as  they  would  have  if  those 
things  were  so.  I  have  seen  male  senile  hypochondriacs  get  very  erotic 
mentally,  with  no  sexual  power.  They  would  want  female  nurses  about 
them ;  would  have  them  wash  and  meddle  with  their  organs  of  genera- 
tion; would  wet  and  dirty  the  bed  in  order  to  be  washed  by  a  female 
nurse;  have  enemata  administered,  while  all  this  time  they  would  affirm 
that  they  had  no  stomach;  that  they  could  take  no  food;  that  their 
bowels  were  never  moved ;  and  that  they  were  so  weak  that  any  motion 
was  an  intense  pain. 

That  hypochondriacal  delusions  are  determined  at  times  by  peripheral 
organic  disease  is,  I  think,  sufficiently  proved  by  pathological  evidence. 
Many  cases  of  hypochondriacal  melancholia  are  caused  by  want  of  work, 
want  of  rational  interest  in  life,  by  sluggishness  of  mind,  selfish  indul- 
gences such  as  well-off  old  bachelors  practise,  by  over-eating  and  little 
exercise,  by  too  routine  modes  of  Avork  and  living.  For  these  the  treat- 
ment must  be  work  and  activity  and  change.  I  knew  such  a  man  cured 
by  losing  his  fortune,  and  having  to  work  hard  for  his  living,  and  a 
woman  cured  by  marrying  a  poor  widower  with  seven  children.  I  have 
known  a  mother  cured  by  losing  a  child.  In  fact,  every  variety  of 
melancholia  is  often  cured  by  a  great  domestic  loss,  a  real  grief  taking 
the  place  of  and  driving  out  the  morbid  mental  pain ;  but  before  this  can 
occur,  the  nutrition  must  be  improved. 

There  is,  of  course,  no  dividing  line  between  the  hypochondriacal 
variety  of  melancholia  and  any  other  form.  Especially  it  runs  into  that 
variety  that  I  have  called  delusional  melancholia,  of  which,  in  fact,  it  may 
be  regarded  as  a  less  severe  variety.  When  the  delusions  in  that  form 
refer  to  the  bodily  organs  or  the  patient's  health,  it  is  difficult  in  some 
cases  to  say  whether  the  word  "hypochondriacal"  applies  or  not. 

Delusional  Melancholia. — Bj  this  term  I  do  not  mean  melancholia 
with  delusions.  In  that  case  nearly  all  melancholic  patients  would  come 
under  this  class.  I  mean  by  it,  that  variety  of  the  disease  in  which 
delusions,  or  a  delusion,  are  from  the  beginning  the  most  prominent 
mental  symptom,  in  which  those  delusions  remain  throughout  the  disease 
of  the  same  character,  in  very  many  being  what  are  called  fixed  delusions 
in  contradistinction  to  delusions  that  change  in  kind,  or  subject,  or  degree. 
As  a  general  rule,  in  this  variety  of  melancholia  the  delusion  stands  out 
80  that  the  friends  of  the  patient  call  it  the  cause  of  his  disease,  and  say 
that  if  he  could  get  rid  of  it  he  would  be  all  right.  It  is  the  support  on 
which  all  the  mental  pain  and  depression  seem  to  hang.  To  those  Avho 
do  not  consider  the  nature  of  the  disease,  the  delusion  seems  the  primary 
and  causal  event,  the  depression  the  secondary,  and  resulting  just  as 
when  a  prosperously  happy  man  loses  his  wife  and  becomes  sad :  his  loss 
is  the  cause  of  his  grief.  In  some  cases  this  may  even  be  so,  but  in  by 
far  the  majority  of  them  the  delusion  and  the  depression  are  both  results 
of  the  same  cause,  viz.,  constitutional  disorder  of  the  brain,  that  being 
developed  out  of  hereditary  tendency,  and  excited  into  action  by  periph- 


STATES    OF    MENTAL    DEPKESSION.  73 

eral  disease  in  some  other  part  of  the  body,  by  blood  poisoning,  or  by 
unphysiological  modes  or  conditions  of  life. 

The  delusions  of  melancholies  are  almost  infinite  in  number  and 
variety.  I  have  had  the  chief  delusions  of  about  one  hundred  put  down 
just  as  they  were  expressed  to  me  (see  p.  88).  A  sadder  list  of  the 
causes  of  human  misery,  if  they  were  real,  it  would  not  be  easy  to  find. 
To  the  unfortunate  men  and  women  who  hold  these  beliefs  they  are  as 
real  as  if  they  had  been  true.  They  are  enough  to  furnish  another 
Dante  with  the  causes  of  torture  for  another  Inferno.  It  is  true  they 
were  not  all  fixed  delusions  of  the  delusional  variety  of  melancholia. 
To  give  a  right  idea  of  it,  I  shall  classify  the  delusions  somewhat,  and 
give  one  or  two  cases  representing  each  kind.  The  first  kind  of  case  I 
shall  speak  of,  is  that  most  nearly  allied  to  the  hypochondriacal  last 
described,  where  the  delusions  refer  to  the  patient's  body  or  health,  or  to 
the  performance  of  the  bodily  functions.  These  are  very  interesting 
from  the  physician's  and  the  physiologist's  point  of  view,  for  the  one 
expects  that  by  curing  any  bodily  disease  present,  he  will  cure  the 
delusion  ;  and  the  other  finds  in  such  a  connection  of  mental  disturbance 
with  bodily  disorder  a  sure  proof  of  the  relationship  between  certain 
parts  of  the  brain  and  body.  Not  that  we  can  in  all  cases  demonstrate 
during  life  or  after  death  such  a  direct  connection.  There  is  a  very 
common  kind  of  case  where  the  delusions  refer  to  the  stomach  and 
bowels ;  I  call  them  the  visceral  or  abdominal  melancholies.  While  they 
may  be  regarded  as  having  something  in  common  with  the  hypochon- 
driacal cases  described,  yet  they  are  of  a  far  more  serious  character. 
Their  delusions  are  more  intensely  believed  in,  and  the  mental  depression 
is  much  more  profound.  There  are  not  only  suicidal  feelings  and  expres- 
sions, but  serious  attempts  in  many  cases.  The  organic  functions  and 
appetites  are  far  more  interfered  with.  The  appetite  for  food  is  paralyzed, 
and  often  that  for  drink.  The  sense  of  organic  satisfaction  in  eating, 
digestion,  and  alimentation,  generally  is  changed  to  one  of  uneasiness  or 
pain.  The  patients  thus  get  wasted.  Sometimes  real  pain  is  felt  in  the 
abdomen.  Many  of  them  complain  of  an  intense  sinking  at  the  epigas- 
trium, very  like  that  which  combined  hunger  and  fatigue  produce  in 
healthy  persons.  Some  complain  of  a  constant  fulness  in  the  abdomen, 
others  of  the  disagreeable  feeling  that  costiveness  produces,  others  of  a 
constant  sensation  of  emptiness  and  faintness.  The  fancies  and  delusions 
attached  to,  and  arising  out  of,  those  real  sensations  are  most  various,  as 
may  be  seen  by  referring  to  the  list  of  melancholic  delusions  I  shall  give 
(see  p.  88).  All  exaggerate  their  costiveness.  All  say  their  food  does 
and  will  do  them  no  good.  They  are  so  far  right,  that,  put  as  much 
food  as  you  like  into  their  stomachs,  it  does  not  nourish  as  in  health. 
Some  say  they  have  no  stomachs,  some  no  gullets.  All  say  that  the 
food  will  not  digest.  Some  say  they  have  foul  breaths  and  ^mells  from 
their  bodies  that  make  them  offensive  to  those  about  them.  Some  say 
that  they  have  syphilis ;  some  that  they  are  being  poisoned,  indeed,  this 
is  common  ;  some  that  the  devil,  or  mice,  or  rats,  or  cats,  are  inside  them. 
The  sense  of  taste  is  certainly  perverted  in  most  of  the  cases,  so  that 
food  tastes  badly. 

All  take  food  without  enjoyment  of  it.     Some  take  it  only  because 


74  STATES    OF    MENTAL    DKPHESSION. 

they  know  they  will  be  forced  to  do  so  if  they  refuse ;  while  others  resist 
any  persuasion,  and  have  to  be  fed  forcibly  by  means  of  tubes  passed  into 
the  gullet  or  stomach.  Such  cases  are  often  suicidal ;  they  are  always 
difficult  to  manage.  They  are  all  thin  and  sallow,  and  some  of  them  die 
of  starvation,  with  plenty  of  food  in  their  stomachs.  In  some  of  the 
older  cases  there  is  a  tendenc}'  to  alternate  constipation  and  obstinate 
diarrhoea. 

I  had  under  my  care  in  the  Carlisle  Asylum  two  most  interesting  cases 
(brothers),  both  of  whom  were  visceral  melancholies,  and  both  of  whom 
had  the  same  delusions,  viz.,  that  their  bowels  were  obstructed,  etc. 
Dr.  Campbell  published  an  account  of  them,*  of  which  this  is  an  abstract: 

Ttvo  Cases  of  Visceral  Melancholia  {brothers).  Delusions  that  their 
bowels  were  never  moved  ;  requiring  forcible  feeding  ;  death  ;  bile-duct 
found  obstructed  in  one,  and  large  intestine  constricted  in  the  other. 

A.  N.  Admitted  into  the  Carlisle  Asylum  on  February  16,  1865. 
Male  ;  sixty  years  of  age. 

No  hereditary  predisposition  existed  as  far  as  could  be  ascertained,  and 
this  was  the  first  attack  of  insanity.  Mentally,  he  had,  at  the  outset  of 
tlie  attack,  been  very  dull  and  very  hypochondriacal  in  his  fancies. 
His  bodily  health  had  been  tolerably  good.  He  had  been  impulsively 
dangerous ;  but  had  not  attempted  or  threatened  suicide.  On  admission 
he  was  found  to  be  above  the  average  height,  well  built,  and  in  fair 
bodily  health.  Mentally  he  was  very  dull  and  desponding.  His  memory 
was  good.  He  could  speak  coherently  and  answer  questions  correctly, 
but  could  not  carry  on  a  conversation  owing  to  his  always  recurring  to 
his  bodily  condition,  which  he  described  thus :  that  his  belly  was  so 
much  swollen  that  he  could  not  take  any  food  ;  that  he  never  got  anything 
through  him ;  and  that  when  he  took  castor  oil  it  came  away  without 
moving  his  bowels.  Nothing  unusual  could  be  discovered  in  the  state  of 
his  abdominal  viscera. 

April  1. — Mentally  remains  the  same  as  at  admission  ;  is  in  better 
bodily  health ;  works  on  farm.  No  one  can  speak  to  him  or  ask  him  a 
question  without  his  saying — "  I  can't  get  aught  through  me.  Will  you 
give  me  some  medicine  ?  I  am  about  burstin'.'"  His  bowels,  however, 
are  regularly  moved,  and  he  takes  his  food  fairly. 

July  1. — Little  change;  at  times  refuses  his  food,  saying  that  he  is 
"bunged  up." 

October  1. — A  short  time  ago  refused  his  food  for  three  days,  and  had 
to  be  fed  once  w'ith  the  stomach-pump. 

Little  change  is  reported  to  have  taken  place  in  the  mental  or  physical 
state  of  the  patient  for  two  years  and  a  half,  when  he  had  again  on 
several  occasions  to  be  fed  with  tube,  owing  to  his  persistent  starvation 
on  the  ground  that  his  intestines  were  full.  During  1871,  on  several 
occasions,  he  had  to  be  fed.  In  1872  he  was  most  miserable  in  mind, 
frequently  contemplated  committing  suicide,  and  at  least  on  one  occasion 
attempted  to  strangle  himself.     He  wanted  to  hang  himself  with  his 

^  Journ.  Ment.  Science,  Jan.  1875. 


STATES    OF    MENTAL    DEPRESSION.  75 

braces,  and  on  several  occasions  tore  his  rectum  and  anus  most  severely, 
thinking  that  this  passage  was  shut  up.  He  went  about  the  wards  shout- 
ing that  he  had  "  forty  days'  meat  in  his  belly,"  that  he  was  "  bunged 
up,"  etc. ;  and,  if  permitted,  would  spend  most  of  the  day  on  the  water- 
closet.  A  dose  of  medicine  always  produced  an  alvine  evacuation  of 
normal  color ;  but,  owing  to  the  patient's  dirty  habits,  and  the  practice 
which  he  said  he  Avas  forced  to,  and  which  he  termed  "hoAvking  himself," 
the  form  of  his  stools  could  not  be  accurately  ascertained.  During  this 
year  both  his  ears  became  slightly  swollen  (the  insane  ear),  then  shrank, 
and  became  much  misshapen. 

On  October  16,  1874,  having  gradually  got  weaker,  without  any 
marked  symptom  of  any  special  disease,  he  died.  Almost  his  last  words 
were  that  he  had  forty  days'  meat  in  his  belly. 

Autopsy — Head. — There  was  an  abnormally  large  amount  of  fluid 
under  the  membranes,  and  the  convolutions  were  considerably  atrophied. 
Section  of  brain  showed  it  to  be  rather  softer  than  normal.  Sufficiently 
rich  in  puncta  in  some  parts ;  at  base  of  brain  it  presented  a  slightly 
reticulated  appearance  from  atrophy  round  minute  vessels.  The  floors 
of  the  lateral  ventricles  were  studded  Avith  small  granulations. 

Chest. — In  the  lower  lobe  of  the  left  lung,  at  its  outer  surface,  there 
was  a  large  vomica  containing  dark  grumous  fluid,  and  on  the  pleural 
coat  of  the  lung  there  was,  outside  the  cavity,  some  deposit  of  gray 
tubercle. 

Abdomen. — Liver  normal ;  duct  from  gall-bladder  and  pancreas 
patent.  The  gall-bladder  contained  a  considerable  amount  of  thin 
bile.  Stomach  normal — contained  some  food ;  small  intestine  normal 
through  its  course  ;  large  intestine  contained  a  considerable  amount  of 
rather  hard  yellow  feces.  The  large  intestine,  fifty  inches  from  the 
caput  Cificum,  and  two  and  a  half  inches  above  the  sigmoid  flexure,  had 
a  very  constricted  part  three  inches  in  extent  and  six-tenths  of  an  inch 
in  diameter.  Above  the  stricture  the  gut  was  two  inches  in  diameter. 
The  portion  of  gut  below  this  to  the  anus  was  normal  in  calibre. 

A.  0.  Admitted  June  22,  1868,  set.  61.  No  other  hereditary  pre- 
disposition as  far  as  known,  except  that  he  is  a  brother  of  A.  N.  No 
cause  could  be  assigned  for  the  attack.  He  is  stated  to  have  been  insane 
for  two  months ;  previously  he  had  been  a  steady,  hard-Avorking  man. 
The  first  mental  symptoms  noticed  were  great  dulness,  hypochondriacal 
fancies ;  latterly  he  had  become  Avorse — very  melancholic  and  suicidal. 
He  complained  much*  of  abdominal  discomfort,  indigestion,  and  costive- 
ness.  On  admission  he  Avas  found  to  be  a  middle-sized  man,  old-looking 
for  his  age;  his  tongue  clean.  Temperature  97°.  Pulse  60.  Skin 
and  conjunctivae  slightly  tinged  yellow.  Bronchitic  rSles  heard  over 
both  lungs.  Abdominal  viscera  seemed  normal.  Mentally  was  most 
dull  and  miserable,  Avringing  his  hands,  complaining  that  he  can  get 
"nothing  through  him,"  that  his  "belly  is  much  swollen,"  wishing  him- 
self dead,  saying  that  he  should  be  hanged,  etc. 

July  3d. — Patient  has  been  most  miserable  and  dull  since  admission ; 
if  permitted,  would  spend  most  of  the  day  on '  the  Avater-closet,  trying  to 
defecate,  and,  even  after  his  boAvels  have  been  cleared  out  by  the  action 
of  medicine,  persists  that  they  are  full,  that  he  needs  medicine,  and, 


76  STATES    OF    MENTAL    DEPRESSION. 

though  not  so  noisy  as  his  brother,  goes  about  complaining,  in  almost 
the  same  words,  that  he  is  "bunged  up,"  etc. 

He  continued  in  the  wretched  mental  state  described  up  to  October, 
1869.  He  had  been  treated  with  vegetable  tonics  and  blue  pill,  frequently 
repeated,  as  it  had  been  noticed  that  his  stools  were  clay-colored ;  and  as 
his  boAvels  were  very  costive,  aperient  medicine  had  been  given  him  at 
intervals.  He  refused  his  food  entirely  on  the  17th  of  October,  saying 
he  was  going  to  burst,  he  was  so  full  that  he  could  get  nothing  through 
him,  etc.  He  was  fed  twice  a  day  with  the  stomach-pump  up  to  the 
24th  of  October,  when,  owing  to  his  most  exhausted  state,  his  struggling 
to  resist  the  feeding,  and  especially  his  having  almost  died  from  suffoca- 
tion by  the  accumulation  of  mucus  in  his  throat  during  paroxysms  of 
coughing  while  being  fed,  it  was  deemed  unsafe  longer  to  feed  him. 
Enemas  were  given  him  several  times  a  day,  and  small  quantities  of 
liquid  food  were  taken  by  the  mouth.  He  sank,  and  died  on  November 
2,  1869. 

Autopsy — Head. — The  whole  brain  was  very  cedematous.  Fornix 
almost  diffluent,  and  corpus  callosum  of  both  sides  extremely  soft.  The 
optic  thalamus  of  the  left  side  was  in  a  more  softened  state  than  the  right. 
The  cerebellum  was  abnonnally  soft  and  oedematous. 

Chest. — The  lower  portion  of  the  lung  was  much  congested,  and  con- 
tained innumerable  small  points  of  tubercular  deposit.  The  lower  lobe 
of  the  left  lung  was  congested,  and  full  of  minute  points  of  tubercular 
deposit ;  its  upper  lobe  was  slightly  congested,  and  contained  a  few  de- 
posits of  tubercle. 

Abdomen. — Liver  slightly  dark  in  color,  otherwise  appeared  normal ; 
gall-bladder  very  small  and  shrunken,  its  walls  were  very  much  thickened, 
it  contained  a  little  black  bile.  The  gall-bladder  and  pancreas  had  sep- 
arate ducts  entering  the  duodenum,  that  from  the  pancreas  entering 
lowest.  The  duct  from  the  gall-bladder  was  not  patent  at  its  termina- 
tion ;  it  ended  in  a  cul-de-sac  of  the  intestinal  wall.  The  wall  of  the 
intestine  was  thickened  at  this  part,  and  looked  like  an  ulcer  inside  of 
the  intestine. 

These  cases  show  that  different  kinds  of  abdominal  distress  and  dis- 
turbed alimentation  may  excite  the  same  delusion.  Extreme  constipation 
existed  in  both  cases,  but  from  quite  different  causes — mechanical  ob- 
struction in  the  one,  and  lack  of  bile  in  the  other.  We  know,  of  course, 
that  neither  constipated  bowels,  nor  lack  of  bile,  nor  mechanical  obstruc- 
tion, is  necessarily  followed  by  such  mental  delusions.  For  these  we  need 
something  else,  viz.,  brain  convolutions  predisposed  to  disordered  action 
which  results  in  a  mental  misinterpretation  of  real  pain  or  organic  dis- 
comfort ;  and  in  those  two  brothers,  though  their  family  history  was  un- 
known, that  cause  of  the  insanity  was  no  doubt  present  in  the  shape  of  a 
hereditary  neurosis.  One  is  justified  in  thinking  that  both  causes  Avere 
needed  to  produce  the  result  in  those  men,  who  might  have  died  reputedly 
sane  but  for  the  abdominal  diseases  which  converted  the  heredity  from  a 
potentiality  into  an  actual  disorder.  It  will  be  observed  that  the  brain 
in  both  cases  presented  signs  of  organic  degeneration. 

There  is  no  doubt  a  special  tendency  for  abdominal  and  cardiac  injuries 
and  diseases  to  be  accompanied  by  mental  depression  or  a  sense  of  vague 


STATES    OF    MENTAL    DEPRESSION.  77 

discomfort,  which  is  the  opposite  of  the  feeling  of  general  well-being  and 
organic  satisfaction. 

The  two  following  are  cases  where  an  organic  lesion  was  found  after 
death,  that  had  evidently  determined  the  character  of  the  delusion  : 

The  first  was  a  case  of  visceral  melancholia,  beginning  as  simple 
melancholia,  then  expressing  religious  delusions,  then  visceral  delusions ; 
"no  oesophagus;"  refusal  of  food;  forcible  feeding;  death;  intestine 
large,  and  scybala  found  almost  obstructing  bowel. 

A.  P.,  set.  58.  Disposition  lively,  social,  cheerful.  Habits  active  and 
industrious.  Two  previous  attacks  of  melancholia ;  one  lasted  about  two 
years  ;  treated  at  home,  and  by  change  of  residence.  Paternal  aunt  died 
insane.  Exciting  cause  not  known.  First  symptoms  :  change  of  dispo- 
sition and  habits,  depression,  inactivity,  apathy,  sleeplessness  (treated 
with  morphia).  Recent  symptoms :  deej?  depression,  despair,  religious 
delusions,  e.  g.,  that  there  was  no  hope  for  her,  that  she  had  committed 
an  unpardonable  sin  ;  restless ;  sleepless  ;  no  attempt  at  suicide.  Dura- 
tion of  attack  :  two  months. 

On  admission,  great  depression,  taciturnity,  and  delusions  as  to  her 
spiritual  state.  She  was  quite  coherent  and  free  from  excitement. 
Memory  good.  Physical  condition  poor.  Nervous  system  and  thoracic 
and  abdominal  organs  apparently  healthy.  Appetite  good.  She  slept 
little  for  nine  nights,  getting  no  morphia,  and  missing  it  very  much. 
Took  sufficient  food.  Was  quiet,  reserved,  and  depressed ;  thought  her 
case  a  hopeless  one.  Considerable  improvement  occurred  at  first,  and 
then  greater  depression  and  a  change  in  the  character  of  the  case,  the 
delusions  now  assuming  the  visceral  character.  Became  restless,  excited, 
and  intractable.  Said  she  could  not  live,  and  tried  to  strangle  herself. 
Refused  her  food  because  she  said  she  had  no  gullet.  Grew  steadily 
worse.  Abdomen  full,  and  a  tumor  was  diagnosed.  Persistently  refused 
food.  Had  to  be  fed  with  nose-tube  thi'ice  daily,  and  very  frequently 
vomited  the  meal.  Bowels  had  been  obstinately  constipated ;  laxatives 
and  enemata  being  employed,  caused  unformed  evacuations.  Breath 
became  extremely  ofi"ensive,  mouth  covered  with  sordes.  Died  six 
months  from  beginning  of  attack,  and  four  months  and  one  week  after 
admission  to  the  Asylum. 

Autopsy. — Beyond  very  slight  atrophy  of  the  gray  matter,  there  was 
no  apparent  brain  disease.  The  thoracic  and  abdominal  organs  were 
healthy,  Avith  the  exception  of  the  intestines.  The  intestinal  walls  were 
greatly  distended  at  diffei'ent  parts,  the  large  intestine  being  particularly 
so  affected.  In  the  large  intestine  huge  masses  of  hard  fecal  matter 
were  found,  which  must  have  been  there  for  a  considerable  time,  judging 
from  their  appearance  and  the  amount  of  irritation  set  up  in  the  intestinal 
walls.  On  several  parts  of  the  internal  surface  of  the  latter  there  were 
pretty  considerable  extravasations  of  blood  and  traces  of  inflammatory 
action.  One  huge  mass  of  fecal  matter  seemed  to  block  up  the  external 
orifice  of  the  intestinal  canal. 

Fortunately  all  such  cases  do  not  terminate  in  death,  nor  are  they  all- 
accompanied  by  organic  disease  or  obstruction  of  the  viscera.     Most  of 
them  are  incurable,  and  yet  after  death  we  find  no  organic  disease  to 
account  for  the  symptoms  during  life.     Indeed,  this  is  the  case  with  the 


78  STATES    OF    MENTAL    DEPRESSION. 

greater  number  of  the  typical  cases.  As  the  result  of  a  statistical  inquiry 
into  this  form  of  insanity,  taking  all  the  cases  I  had  notes  of,  I  arrived 
at  the  following  results.  In  the  first  place,  out  of  the  visceral  cases  only 
one-fifth  completely  recovered,  a  few  making  a  partial  recovery,  the  acute 
misery  and  the  delusions  passing  off,  but  some  depression  and  some 
enfeeblement  of  mind  remaining.  Of  those  who  recovered  several 
relapsed  into  the  same  mental  state  at  older  periods  of  life,  and  then 
remained  incurable.  Another  fact  in  regard  to  this  disease  came  out  in 
the  statistics,  viz.,  that  every  typical  case  was  over  fifty  years  of  age. 
Some  of  the  cases  in  which  there  was  no  organic  disease  found  after  death, 
had  been  characterized  by  a  tendency  to  a  sort  of  passive  diarrhoea  during 
the  later  stages  of  the  disease,  the  best  cure  for  Avhich  I  always  found  to 
be  the  recumbent  position.  It  seemed  to  be  a  diarrhoea  from  deficient 
motor  innervation  of  the  boAvels — a  sort  of  alimentary  atony.  This  was 
usually  accompanied  by  tissue  wasting  throughout  the  body,  a  low  tem- 
perature, an  incapacity  to  resist  cold,  a  blue  chilly  state  of  the  extremities, 
and  a  tendency  to  congestions,  tubercles,  and  low  inflammations.  In 
fact,  such  conditions  seem  the  natural  termination  of  life  in  such  cases ; 
or  intercurrent  diseases  engendered  by  those  conditions,  such  as  bronchitis, 
catarrhal  pneumonia,  tuberculosis,  gangrene  of  lungs,  etc. 

The  following  is  another  very  good  example  of  this  important  and 
troublesome  class  of  cases,  there  being  present  delusional  melancholia, 
caused  by  exhaustion  from  over-work,  the  delusions  being  that  all  animal 
food  given  was  human  flesh,  and  was  poison  ;  Avith  refusal  of  food.  Two 
attacks — first  recovered  from  with  perfect  mental  capacity  for  hard  work ; 
second  attack  ending  in  death. 

A.  Q.,  set.  50.  At  first  attack,  which  consisted  of  mental  depression 
and  delusions  that  his  food  was  "raw  human  flesh,"  so  that  he  would  not 
take  it,  he  lost  over  two  stones  in  two  months  the  disease  had  lasted 
before  he  was  placed  under  treatment  in  the  Asylum.  The  cause  had 
been  mental  anxiety  and  over-work,  and  no  heredity  was  admitted. 
The  strange  fancies  of  some  melancholies  were  well  illustrated  by  his 
imagining  that  the  arrow  on  the  paper  in  the  crown  of  his  hat  had  been 
put  there  to  indicate  that  he  would  be  put  in  a  dark  coal-cellar  if  he  did 
not  eat  arrowroot !  He  also  believed  his  food  Avas  poisoned ;  and  he 
would  not  use  the  water-closet,  as  he  imagined  it  would  interfere  Avith  the 
drainage.  He  had  cold  hands  and  feet ;  his  skin  Avas  blue  and  cold  ;  he 
lost  his  big  toe-nail  from  a  chilblain  ;  and  he  had  a  boil  on  his  face.  He 
pointed  to  all  these  things  in  proof  of  his  delusion  that  he  had  been 
poisoned.  He  had  oxaluria,  and  his  boAvels  Avere  costive.  He  was  fed 
well,  got  stimulants  and  fresh  air,  and  gained  in  Aveight ;  but  in  seven 
months  from  the  beginnino;  of  his  illness  he  AAOuld  still  take  no  interest 
in  anything  but  the  state  of  his  boAvels.  In  about  a  year  from  the 
beginning  of  his  illness  he  had  recovered  from  his  depression,  and  had 
got  rid  of  his  delusions,  and  he  Avas  strong  and  stout.  In  eighteen 
months  he  was  doing  an  enormous  professional  business,  implying  the 
greatest  mental  strain,  and  the  exercise  of  the  highest  intellectual  ability. 
He  did  so  for  eight  years,  and  then  the  symptoms,  mental  and  bodily, 
that  I  have  described  came  on  again,  and  he  had  to  be  placed  under 
treatment  in  the  Asylum.     This  time  he  was  over  sixty.     He  was  more 


STATES    OF    MENTAL    DEPRESSION.  79 

emaciated  ;  he  shoAved  marked  signs  of  arterial  degeneration  ;  his  prostate 
was  enlarged,  and  his  urine  troubled  him  both  bv  retention  and  inconti- 
nence  at  dijBerent  times ;  he  was  scarcely  able  to  speak  above  a  whisper ; 
and  in  his  gait,  attitude,  and  movements  he  gave  the  impression  of  an 
old  man.  In  spite  of  every  treatment — tonic,  nerve-stimulant,  fattening, 
and  stimulant — he  grew  worse.  He  was  compelled  to  take  enough  food, 
but  it  did  not  fatten  him.  He  was  constantly  troubled  with  a  mild 
diarrhoea,  and  he  could  not  always  keep  himself  clean.  Whenever  in  any 
form  of  insanity  the  patient  persistently  passes  urine,  and  especially 
feces,  in  his  clothes  or  bed,  it  is  a  bad  sign  on  the  whole.  It  appears  to 
imply  always  a  profoundly  diseased  interference  wdth  the  radical  instincts 
of  man.  The  only  exception  to  this  bad  prognosis  from  this  cause  is 
when  it  happens  in  acute  delirious  mania  and  in  stupor.  The  patient 
was  removed  home,  and  gradually  sank  in  about  nine  months  from  the 
becrinninf»;  of  his  second  attack. 

Such  a  case  shows  that  the  morbid  brain  action,  the  trophic  paralysis, 
the  actual  visceral  derangement  and  its  exaggerated  mental  representation, 
can  all  be  recovered  from.  It  also  shows  that  there  is  liability  to  return 
with  the  decadence  of  function  and  degeneration  of  tissue  of  advancing 
life.  As  we  shall  see  when  I  come  to  speak  of  the  climacteric  period  and 
its  characteristic  mental  disease,  the  great  physiological  crisis  has  much 
to  do  with  such  a  case.  Medicine,  rest,  food,  fresh  air,  nursing,  physio- 
logical conditions  of  life,  can  do  much,  but  they  cannot  arrest  the 
tendency  to  death  inherent  in  tissue,  and  organ,  and  organism,  when 
their  appointed  time  of  living  has  run. 

If  we  could  connect  the  visceral  delusions  and  depressions  in  every 
case  Avith  visceral  lesions,  as  in  the  cases  of  A.  N.,  A.  0.,  and  A.  P.,  we 
should  place  them  in  the  clinical  classification  as  visceral  insanity.  A& 
we  cannot  yet  say  there  is  any  visceral  lesion  or  disorder  at  all  in  many 
of  them,  but  merely  a  delusion  that  there  is,  I  have  simply  described  the 
clinical  facts  in  regard  to  them,  and  avoided  a  new  "form  of  insanity." 

The  following  was  a  complicated  case  of  delusional  melancholia,  with 
one  central  and  many  peripheral  causes  of  irritation  and  exhaustion,  viz., 
a  cancerous  tumor  of  the  middle  lobe  of  brain,  disease  of  kidneys,  liver, 
pylorus,  etc. 

A.  Q.  A.,  set.  58,  a  lady  of  good  education,  cheerful  and  frank  dispo- 
sition, domestic  and  industrious  habits,  who  had  enjoyed  good  health,  and 
had  a  family  of  several  children.  Temperament  not  neurotic.  No 
hereditary  predisposition  to  insanity.  Predisposing  cause  of  attack 
seemed  to  be  domestic  anxiety,  and  a  sudden  alarm  of  fire.  Had  been 
falling  oif  in  flesh,  appetite,  and  strength  before  mental  attack,  but  became 
depressed  some  weeks  before  admission,  and  soon  became  possessed  with 
the  delusion  that  she  was  very  wicked,  that  she  had  syphilis,  and  would 
infect  those  round  her.  She  refused  food,  was  sleepless,  and  imagined 
she  had  no  passage  in  her  bowels. 

On  admission  there  was  extreme  depression ;  says  she  is  very  wicked, 
is  lost,  has  syphilis,  and  is  not  fit  to  be  here.  Has  an  anxious,  worn, 
pinched  expression  of  face.  Cannot  be  interested  in  anything  outside 
herself.  Memory  seems  fairly  good.  Is  coherent,  and  can  answer 
questions;  very  thin;  color  very  bad.     Has  enlargement  of  the  thyroid 


80  STATES    OF    MENTAL    DEPRESSION. 

body,  with  prominent  eyeballs.  No  paralysis  or  anaesthesia.  Tongue 
slightly  coated.  Bowels  very  costive.  Pulse  88,  weak.  Temperature 
98.3°.  Patient  was  ordered  a  tonic — quinine  and  hydrochloric  acid — 
and  to  have  two  glasses  of  sherry  daily,  with  good  nursing,  and  plenty  of 
easily  digested  food  and  fresh  air. 

For  a  time  patient  showed  a  slight  improvement,  but  this  proved  very 
temporary,  and  the  melancholic  condition  became  aggravated.  She  slept 
badly,  occasionally  having  a  good  night,  but  generally  being  restless, 
with  broken,  disturbed  sleep.  The  appetite  was  much  impaired,  patient 
taking  very  little  food,  and  ultimately  refusing  food  altogether,  so  that 
on  one  occasion  she  had  to  be  fed  with  the  stomach-pump.  The  tongue 
was  clean,  but  dry  ;  the  bowels  were  costive,  and  had  to  be  regulated  by 
occasional  doses  of  compound  licorice  powder  and  other  aperients.  Patient 
had  a  pinched,  anxious  expression  of  face,  and  lost  flesh.  Mentally  she 
was  in  a  condition  of  great  depression,  with  numerous  delusions  of  a 
melancholic  character.  She  fancied  that  she  was  lost  to  all  eternity, 
that  she  had  misconducted  herself  in  youth,  and  that  she  was  now  suffer- 
ing from  a  disease  which  she  had  contracted  at  that  time ;  that  she  had 
ruined  her  husband  and  family,  and  that  there  was  no  place  for  her  at 
home  at  all.  Along  with  this  there  was  considerable  enfeeblement  of 
mind ;  she  was  childish,  querulous,  and  unreasoning  in  her  conduct ;  and 
her  power  of  attention  and  her  memory  were  much  impaired,  especially 
as  to  recent  events.  After  having  been  in  the  asylum  for  weeks,  she 
would  maintain  that  it  was  only  one  long  day  since  she  came ;  she  com- 
plained that  the  days  never  came  to  an  end,  and  that  she  was  compelled 
to  take  an  extraordinary  .number  of  meals  in  each  day.  This  perversion 
of  the  sense  of  time  and  number  is  not  uncommon  in  melancholia.  When 
asked  to  go  to  dinner,  she  Avould  querulously  reply  that  it  was  not  half 
an  hour  since  she  had  taken  breakfast.  She  showed  little  interest  in 
what  passed  around  her ;  could  be  got  to  take  little  or  no  part  in  work 
or  amusements,  but  was  always  harping  upon  her  own  miserable  condi- 
tion, and  in  conversation  giving  ready  expression  to  her  delusions.  She 
was  very  disinclined  to  take  the  usual  open-air  exercise,  and  would  meet 
the  doctor  on  his  morning  visit  with  the  constant  request  that  she  should 
be  allowed  to  remain  in  the  parlor,  as  she  was  too  weak  to  walk.  When 
compelled  to  go  out,  she  thought  that  she  was  being  treated  unkindly, 
and  this  idea  at  times  almost  amounted  to  a  delusion  that  she  was  per- 
secuted by  the  attendants ;  and  when  visited  by  her  friends  she  would 
frequently  make  ungrounded  complaints  against  them. 

With  occasional  slight  variations  from  time  to  time,  patient's  mental 
condition  during  the  winter  continued  much  the  same  as  that  noted  above 
— depression  and  enfeeblement,  with  delusions  of  a  melancholic  type. 
But  during  all  this  time  her  physical  health  Avas  steadily  deteriorating ; 
she  took  her  food  badly,  and  only  with  much  coaxing  (though  the 
stomach-pump  did  not  again  require  to  be  used) ;  she  was  restless  at 
nights ;  the  bowels  were  still  costive  more  or  less.  There  were  great 
emaciation,  a  slightly  jaundiced  tint  of  the  conjunctiva,  and  a  markedly 
cachectic  appearance,  such  as  to  make  one  at  once  suspect  that  the  patient 
might  be  laboring  under  organic,  and  possibly  malignant,  disease.  From 
time  to  time  repeated  physical  examination  of  the  thorax  and  abdomen 


STATES    OF    MENTAL    DEPRESSION.  81 

was  made,  with  the  object  of  detecting  any  organic  disease  that  might 
exist,  but  no  evidence  of  such  disease  could  be  found.  Beyond  frequently 
containing  a  very  large  quantity  of  urates,  the  urine,  indeed,  usually 
showed  nothing  abnormal.  It  was  difficult  to  make  a  satisfactory  ex- 
amination of  the  organs,  as  the  patient  complained  bitterly  whenever  she 
was  touched,  and  her  statements  as  to  the  parts  in  which  she  felt  pain  or 
tenderness  on  pressure  could  not  be  relied  on.  Great  oedematous  swelling 
appeared  in  the  feet,  and  gradually  extended  up  the  legs.  The  pulse 
became  small  and  very  thready,  and  latterly  could  sometimes  scarcely 
be  felt  at  the  wrist.  The  bowels  at  this  time  were  much  more  regular 
than  previously,  and  the  stools  more  natural  in  appearance.  Patient 
grew  weaker  and  Aveaker,  and  ultimately  sank,  a  year  after  admission. 

Autopsy. — Body  much  emaciated  ;  extensive  bed-sore  over  sacrum. 

Brain. — Vessels  at  base  atheromatous.  Vertex  healthy  looking. 
There  was  a  tumor,  the  size  of  a  hen's  egg,  growing  from  the  upper  part 
of  petrous  portion  of  the  left  temporal  bone,  weighing  half  an  ounce,  and 
attached  to  the  inner  table  of  the  bone,  which  was  somewhat  softened. 
The  tumor  was  encysted  in  the  brain  matter,  but  not  attached  to  it,  lying 
quite  free  in  a  cup-shaped  cavity.  The  contiguous  brain  substance  was 
flattened  out  and  somewhat  softened. 

The  cancerous  mass,  on  microscopic  examination,  was  found  to  consist 
of  small  cells  lying  in  the  meshes  of  a  delicate  stroma,  although  much 
resembling  brain  matter,  but  distinguishable  from  it  by  the  absence  of 
the  characteristic  larger  brain  cells  of  the  gray  matter.  The  brain  was 
softened  near  the  tumor,  and  very  anaemic. 

Abdomen. — There  were  several  small  secondary  masses  of  cancer  at 
the  pyloric  end  of  stomach,  the  orifice  of  which  was  constricted.  No 
secondary  cancer  in  liver,  kidneys,  glands,  or  other  organs.  The  splenic 
artery  was  enormously  tortuous  and  dilated.  Liver  was  fatty,  with 
thickening  of  the  coats  of  its  arteries  and  bile-ducts,  and  considerable 
increase  of  fibrous  tissue  round  them.  The  fibrous  tissue  round  the  bile- 
ducts  was  deeply  stained  Avith  bile  even  to  the  smallest  duct. 

Kidneys. — Right  kidney  full  of  very  large  cysts;  substance  otherwise 
normal.  Left  kidney  had  marked  cystic  degeneration.  The  renal  sub- 
stance was  almost  gone,  its  place  being  taken  by  numbers  of  cysts,  many 
of  them  containing  dark  fetid  fluid  matter. 

In  regard  to  the  duration  of  each  of  the  distinct  diseases,  the  only 
guides  one  has  in  forming  an  opinion  are  the  pathological  appearances 
after  death.  Not  one  of  them  produced  unequivocal  symptoms  during 
life  by  which  they  could  have  been  certainly  diagnosed,  or  their  course 
determined.  The  cystic  condition  of  kidney  seemed  undoubtedly  to  have 
been  the  first  departure  from  health.  But  then,  on  admission,  it  did  not 
cause  albuminuria,  oedema,  or  any  other  symptoms  referable  to  renal 
diseases.  It  was  only,  in  fact,  within  two  months  of  death  that  this  was 
so.  The  contraction  at  the  pyloric  orifice  of  the  stomach  must  have 
existed  some  time,  but  there  are  no  data  for  saying  how  long.  There  is 
fair  reason,  however,  for  connecting  this  with  the  loss  in  flesh,  falling  oft 
in  appetite,  and  discomfort  in  the  region  of  the  stomach  and  bowels, 
which  came  on  a  few  months  before  the  insanity.     The  liver  had  clearly 

6 


82  STATES    OF    MENTAL    DEPRESSION. 

been  disordered  in  its  functions ;  and  obstruction  of  its  ducts  had  been 
suspected  by  us  during  her  disease,  and  the  urine  examined  for  bile,  just 
a  trace  being  once  found  in  it.  In  fact,  I  had  a  strong  suspicion  of  ob- 
struction of  its  ducts,  from  the  mental  symptoms  being  similar  to  those 
of  A.  N.  and  A.  0.  (pp.  74  and  75). 

The  cancerous  tumor  of  the  brain  had  been  utterly  unsuspected,  and 
had  produced  no  symptoms  discoverable  -whatever,  either  sensory  or 
motor.  Such  a  tumor  as  that,  I  cannot  imagine  would  have  grown  to 
such  a  size  within  the  skull,  where  there  is  so  little  room  for  ready  ex- 
pansion, in  less  than  twelve  months,  and  probably  it  took  a  longer  time 
than  that.  My  experience  of  such  tumors  would  lead  me  to  say  that  its 
duration  was  over  a  year. 

The  cause  of  death  in  this  case  was  really  the  exhaustion  and  failure 
of  bodily  nutrition,  caused  by  the  presence  of  all  the  diseases  and  morbid 
states  of  mind  and  body.  Their  combined  evil  efiects  had  reached  that 
point  which  was  incompatible  with  life. 

The  mental  symptoms  were  from  the  beginning,  in  many  respects,  of 
that  type  of  melancholia  which  has  been  associated  with  disorders  or 
diseases  of  the  alimentary  canal.  The  cry  of  the  organism  for  suitable 
nutriment,  which  is  revealed  to  consciousness  as  appetite,  was  quite 
abolished,  and  there  was  instead,  at  one  time,  a  strong  repugnance  to 
food.  Digestion  was  impaired.  There  were  clearly  strong  feelings  of 
organic  discomfort  after  eating.  The  bowels  were  very  costive,  and  her 
delusions  exaggerated  their  costiveness  into  months  between  each  move- 
ment. Her  abdomen  and  abdominal  muscles  felt  hard  and  stretched. 
The  hypersesthesia  she  had  was  referred  for  the  most  part  to  her  bowels. 
"With  all  this  there  was  extreme  emaciation,  though  plenty  of  nourishment 
was  taken  into  the  stomach. 

I  think  one  may  confidently  refer  the  direct  cause  of  the  special  delu- 
sions in  all  those  cases  to  a  disordered  working  of  that  portion  of  the 
brain  which  presides  over  the  function  of  alimentation  ;  and,  secondarily, 
to  a  disordered  working  of  the  organic  nerve  ganglia  that  so  abound  in 
the  abdomen — the  sympathetic  system  of  nerves,  the  semilunar  and 
visceral  ganglia,  and  the  small  nerve  ganglia  in  the  coats  of  the  bowels. 
Ferrier  thinks  that  the  posterior  lobes  of  the  brain  are  the  seat  of  the 
organic  brain  functions,  but  there  is  no  proof  of  this,  and  the  lower 
portions  of  the  middle  lobes  are  yet  quite  unappropriated  as  to  special 
functions.  It  may  be  that  their  functions  are  those  of  presiding  over 
and  regulating  alimentation  and  digestion.  The  real  cause  of  the  aboli- 
tion of  the  normal  food  appetites  in  so  many  diseases  and  states  of  dis- 
ordered health,  and  their  perversion  in  other  instances,  is  unknown,  but, 
beyond  a  doubt,  we  must  refer  many  of  them  to  some  central  cause  in  the 
brain.  The  whole  of  A.  Q.  A.'s  case  was  interesting  from  there  being 
disease  in  the  brain  which  probably  caused  the  melancholia,  and  disease 
in  the  abdominal  viscera  which  determined  its  special  character  and  its 
delusions. 

In  two  very  marked  visceral  cases  of  melancholia,  with  delusions  of  no 
stomach  and  intense  repugnance  to  food,  I  have  had  the  semilunar,  and 
many  of  the  sympathetic  ganglia  of  the  abdominal  plexus  taken  out, 


PLATE  VTI. 


James  Robertson  Del^ 


G  V/aterstoniSaas.Litho  Edinburgh 


•f 


STATES    OF    MENTAL    DEFEESSION.  83 

hardened,  and  cut  into  sections,  and  examined  them  microscopically,  and 
in  both  cases  I  found  the  nerve-cells  markedly  degenerated,  atrophied,  and 
pigmented  (see  Plate  VII.,  Fig.  1).  Some  of  the  cells  had  almost  disap- 
peared, and  very  few  of  them  in  any  of  these  sections  were  normal. 
Whatever  are  the  precise  functions  of  those  ganglia,  beyond  a  doubt  they 
could  not  have  been  properly  performed  by  those  diseased  cells. 

The  delusions  refer  to  electricity  or  some  such  imaginary  source  of 
annoyance  in  a  large  number  of  instances,  as  in  this  case,  which  recovered  : 

A.  R.,  ddt.  44 ;  education  average.  Disposition  reserved,  unsocial, 
suspicious,  grasping ;  habits  steady  and  industrious.  One  previous 
attack  of  depression  with  delusions  lasting  a  month ;  treated  and  cured 
by  travel  and  rest;  no  insanity  in  family.  Exciting  cause:  over-work 
and  business  anxiety.  Attack  has  lasted  one  month,  though  he  had 
been  dull  before.  Became  restless  and  sleepless ;  lost  appetite ;  very 
depressed  ;  threatened  violence  to  himself;  was  very  suspicious,  and  abso- 
lutely possessed  with  the  delusion  that  an  electric  battery  was  at  work  in 
his  house  acting  on  him,  and  causing  pain  and  sleeplessness.  On  admis- 
sion, great  depression  shown  in  expression,  language,  and  behavior. 
Talks  all  the  time  about  people  working  on  him  with  an  electric  battery 
in  his  bed,  and  that  enemies  are  conspiring  to  ruin  him.  General  health 
weak;  condition  poor;  tongue  foul;  bowels  costive;  conjunctivae  yellow ; 
muscles  flabby.  For  a  week  after  admission  he  remained  extremely 
depressed,  reserved,  full  of  the  battery  delusions,  and  suspicious,  and 
slept  very  little.  Under  light  digestible  food  and  milk,  tonics,  podophyllin 
every  night,  fresh  air,  and  constant  companionship,  he  improved  steadily, 
became  more  cheerful  and  sociable,  talked  less  of  the  delusions,  slept 
better,  and  had  a  good  appetite.  Within  three  months  he  was  able  to 
live  in  one  of  the  detached  houses ;  and  in  two  months  more  he  was  dis- 
charged recovered,  having  gained  a  stone  and  a  half  in  weight,  looking 
fresh,  and  mentally  quite  happy.  During  recovery  he  passed  through 
the  common  enough  stage  of  belief  in  the  existence  of  the  battery  at  one 
time,  though  he  said  it  Avas  not  worked  on  him  then.  After  complete 
recovery  he  laughed  at  the  whole  idea  as  being  a  morbid  fancy  ;  but  he 
said  his  sensations  had  been  most  uncomfortable,  that  he  used  to  feel 
sudden  pains,  to  twitch  and  jerk  and  jump  up  in  bed,  and  had  imagined 
those  motor  and  sensory  nervous  symptoms  meant  that  he  was  worked  on 
by  a  battery.  The  pathological  explanation  of  them  is  no  doubt  this, 
that  through  brain  disorder  or  peripheral  disease,  neuralgic  and  perverted 
sensations  are  felt,  and  their  meaning  misinterpreted  by  the  disordered 
intellectual  centres,  which  are  at  the  time  not  in  a  condition  to  be  affected 
by  evidence,  or  capable  of  reasoning  rightly.  I  once  had  an  epileptic 
patient  who,  at  times  after  the  regular  fits,  used  to  twitch  in  her  limbs, 
and  who  would  point  to  the  twitchings  (that  were  evidently  accompanied 
by  pain)  and  say — "Look  how  it  works  on  me,"  meaning  that  some  one 
was  electrifying  her.  Such  delusions  of  annoyance  or  being  worked  on 
by  electricity,  magnetism,  or  unseen  agency,  if  they  last  long,  while  the 
depression  abates,  are  very  unfavorable  as  regards  prognosis.  But,  so 
long  as  there  is  distinct  depression,  of  which  these  delusions  are  an 
accompaniment,  the  case  should  be  held  to  be  curable,  a!ld  treated  as  such. 


84  STATES    OF    MENTAL    DEPRESSION'. 

There  is  a  popular  notion  that  religious  cases  of  melancholia  are  veiy 
unfavorable.  It  is  meant  that  cai^es  "with  intense  despontiency  as  to  their 
religious  condition,  and  delusions  as  to  their  eternal  damnation, — as  to 
having  committed  an  unpardonable  sin,  having  offended  the  Holy  Ghost, 
having  led  most  wicked  lives  that  ■will  never  be  forgiven,  having  failed  to 
instruct  their  children  properly  in  religious  truths,  having  caused  much 
sin  in  others  by  their  example,  having  neglected  the  services  of  religion, 
having  been  hypocrites  and  impure  in  heart  and  motive  while  professing 
Christianity,  and  kept  up  religious  appearances  so  as  to  deceive  the 
world,  being  possessed  by  the  devil,  etc., — that  such  cases  never  get  well. 
Ko  doubt  there  are  some  bad  cases  of  religious  delusional  melancholia, 
and  such  patients  are  apt  to  make  a  strong  impression  on  those  who  see 
them.  In  reference  to  them,  the  religious  superstitions  of  the  Middle 
Ages  as  to  diabolic  possession  still  cling  in  the  popular  mind.  They  are 
always  taken  to  the  clergy  first  for  comfort  and  spiritual  help.  It  is 
diflScult  to  draw  the  line,  too,  between  them  and  the  religious  ''conviction 
of  sin"  and  doubt  and  depression  which,  according  to  many  systems  of 
theological  belief,  are  a  noiiual  part  of  the  individual  religious  life. 
John  Bunyans  prolonged  depression  and  "darkness,"  which  is  accepted 
by  many  as  a  normal  religious  experience,  having  no  connection  what- 
ever with  mental  disease,  is  sufficiently  like  some  of  the  cases  to  cause 
a  feeling  of  confusion  about  them.  Some  of  the  cases  have  been  called 
by  special  names — Demonomcinia,  etc.  There  is  no  doubt,  too,  that 
the  religious  instinct  of  man  is  one  of  the  deepest  and  most  centiul 
pai'ts  of  his  psychological  constitution,  and  is  often  cultivated  and  devel- 
oped from  childhood  in  a  way  that  few  of  his  other  faculties  are ;  so  that, 
when  perverted,  it  causes  intense  general  emotional  disturbance.  These 
reasons  are  sufficient  to  account  for  the  general  idea  that  the  prognosis  in 
religious  insanity  is  bad.  But,  as  a  matter  of  fact,  this  is  untrue.  A 
very  large  number  of  cases  of  melancholia  have  a  religious  element 
in  them,  and  it  certainly  does  not  prevent  them  fi-om  getting  better. 
The  following  is  an  example : 

A.  S.,  jet.  29.  Disposition  cheerful.  Habits  industrious.  Comes  of 
an  excitable,  eccentric  family.  Cause  of  her  illness  ill-treatment  by  her 
mistress  and  amenorrhoea.  First  symptoms,  mental  confusion  and 
depression,  and  falling  off  in  bodily  looks,  appetite,  strength,  and  her 
head  feeling  "queer."  On  admission  she  had  mental  depression,  as  indi- 
cated by  her  expression,  attitude,  and  the  general  tone  of  her  convei*sa- 
tion.  There  was  also  slight  mental  enfeeblement ;  her  memory  seemed  to 
be  greatly  impaired.  She  labored  under  various  delusions  of  a  religious 
kind,  e.  g.^  that  she  was  the  greatest  sinner  alive,  and  liad  committed 
many  and  unpardonable  sins.  She  wore  a  very  dejected  aspect.  The 
sensory  fimctions  were  slightly  dulled,  and  the  reflex  functions  impaired. 
She  had  suffered  for  seveiul  months  from  amenorrhoea.  She  was  very 
suicidal.  She  was  the  very  picture  of  misery,  despair,  and  lack  of 
interest  in  the  world  outside  her. 

She  was  put  upon  sulphate  of  quinine  and  iron,  and  aloes,  good  food, 
and  fresh  air  and  employment,  which  she  was  not  at  first  able  to  settle 
herself  to  do.     Af  fii-st  there  was  no  change  for  the  better.     Was  very 


STATES    OF    MENTAL    DEPRESSIOX.  8o 

depressed;  refused  food,  wept  causelessly  at  frequent  intervals,  and 
generally  bemoaned  her  lot  as  being  a  castaAvay  from  God.  Became  dis- 
tinctly worse  mentally.  Had  hallucinations  of  hearing.  Still  refused 
her  food.  In  two  months  had  greatly  improved  in  her  mental  and  bodily 
condition,  and  took  her  food,  but  was  at  times  obstinate  and  wayward.  In 
five  months,  menstruated  for  the  first  time  since  admission,  and  at  once 
her  mental  recovery  was  completed,  and  she  said  she  felt  quite  differently. 
She  had  got  stronger,  stouter,  and  better  looking  before,  but  the  change 
after  menstruation  was  marked  and  immediate.  The  sense  of  religious 
depression  and  despair  disappeared,  and  she  was  cheerful ;  and  religion 
did  not  trouble  her  much  one  way  or  the  other. 

In  this  case  she  had  been  brought  up  in  a  religious  sect  where,  theo- 
retically, religion  was  all  in  all.  When  she  was  miserable,  what  would 
80  naturally  fix  her  morbid  ideas  as  to  the  cause  of  her  condition  as  the 
religious  ideas  in  which  she  had  been  educated  ?  but  they  in  no  way 
affected  the  progress  or  the  favorable  result  of  the  case. 

There  are  some  cases  of  religious  delusional  melancholia  where  the 
depression  is  certainly  very  intense,  the  mental  pain  most  deep,  and  the 
prognosis  very  bad.  Some  of  those  are  persons  with  the  combination  of 
a  highly-developed  religious  instinct  and  a  strongly-marked  heredity  to 
insanity.  If,  along  with  those  two  conditions,  life  is  on  the  wane  with 
the  patient,  and  decadence  of  weight  and  general  vigor  has  begun,  and 
religious  delusional  melancholia  comes  on,  the  outlook  is  often  bad.  The 
following  is  an  example : 

A.  T.,  aet.  45.  No  children.  No  heredity  to  insanity  acknowledged 
by  relatives,  but  this  I  had  reason  to  doubt.  Temperament  melancholic 
and  diathesis  nervous,  but  disposition  had  been  most  cheerful  and  benevo- 
lent ;  habits  active,  especially  in  doing  good,  teaching  classes  among  the 
poor,  and  comforting  the  afflicted.  A  particularly  bright,  cheery  woman 
when  well,  happy  in  her  religion.  She  went  to  a  trying  climate  about  a 
year  ago  and  got  a  little  run  down.  A  few  weeks  before  I  saw  her  she 
had  become  dull  and  lost  her  brightness  and  vivacity.  She  said  she  had 
lost  her  "hope  in  God,"  and  her  comfort  and  assurance  in  religion.  She 
thought  God  had  forsaken  her,  that  she  was  lost,  that  her  former  re- 
ligious life  had  been  tinctured  and  polluted  by  selfishness  of  motive,  and 
that  she  had  been  a  hypocrite  before  God  and  man.  She  would  not  go 
to  church,  and  any  attempt  to  administer  religious  consolation  to  her  in 
the  usual  way  by  clergymen,  engaging  in  religious  exercises  with  friends, 
quoting  suitable  texts,  etc.,  only  made  her  worse.  "  Those  are  not  for 
me,"  she  would  say.  "  I  would  insult  the  Almighty  more  and  more  by 
going  to  church."  Her  subjective  mental  pain  entirely  prevented  her 
from  being  able  to  see  the  cheerful  aspects  of  the  Christian  religion. 
With  these  mental  symptoms  there  had  been  headaches  and  strange 
feelings  in  the  head  to  begin  with,  but  these  passed  off,  as  is  very 
common,  when  the  affective  mental  symptoms  developed  themselves. 
But  there  was  a  furred  tongue,  that  had  been  most  wrongly  treated  by 
purgatives.  When  will  our  profession  fully  understand  that  a  man's 
tongue  m:iy  be  as  furred  and  foul  from  want  of  food,  ,or  from  -an  atonic 
innervation  of  the  stomach  and  bowels,  or  from  a  mere  neurosis,  as  from 


86  STATES    OF    MENTAL    DEPRESSION. 

sluggishness  of  the  iprimce  vice  ?  She  was  menstruating  irregularly.  She 
looked  haggard  and  flabby.  She  had  lost  her  feminine  plumpness,  and 
her  weight  was  much  less  than  it  had  been  in  health.  Her  food-appetite 
was  paralyzed,  eating  giving  her  no  pleasure.  I  prescribed  nitro-muri- 
atic  acid  and  quinine  mixture ;  fattening  diet,  taken  little  and  often ; 
simple  warm  water  enemata  for  the  bowels ;  change  of  scene  among 
intimate  friends ;  stopped  the  knocking  about  in  travel  that  she  had  been 
trying ;  proscribed  religious  talk  of  any  sort,  and  gave  directions  for  her 
being  watched  at  all  times.  But  she  steadily  got  worse,  more  sleepless, 
more  restless  and  agitated,  and  more  miserable,  till  she  was  the  picture 
of  despair ;  became  distinctly  suicidal ;  had  to  be  sent  to  an  asylum,  and 
in  two  years  ^he  passed  into  dementia  with  still  a  melancholic  tinge  to  it, 
as  is  usual  in  the  dementia  that  follows  melancholia. 

This  case  is  the  common  type  of  religious  delusional  melancholia,  but 
there  are  persons  with  religious  melancholia  of  a  far  more  subtle  type 
than  this — persons  of  a  neurotic  diathesis,  lively  fancy,  delicate  feeling, 
and  keen  religious  sentiment  that  has  been  developed  by  much  fostering 
care  from  their  youth  up ;  persons  who  have  had  many  of  the  functional 
neuroses,  martyrs  to  headaches,  varied  by  spinal  irritations;  in  torture 
from  neuralgia  one  day,  and  roused  by  mild  hysterics  the  next.  They 
are  clergymen's  spinster  daughters,  or  the  female  members  of  intellectual 
and  religious  families.  They  suffer  much,  but  they  generally  suffer  it 
patiently.  The  depression  of  feeling  with  them  is  usually  hung  on  some 
subtile  controversial  or  doctrinal  peg,  or  on  an  ethical  or  religious  point, 
so  fine  that  it  seems  to  a  healthy  mind  almost  ridiculous  to  regard  it  as 
of  any  importance.  Such  persons  at  times  undergo  temporary  paralysis 
of  religious  feeling  and  volition,  "  deadnesses,"  and  they  torture  them- 
selves about  it.  Those  people  are  all  thin,  and  to  them  I  preach  the 
gospel  of  fatness,  the  gospel  of  fresh  air,  of  healthy  secular  literature, 
and  active  occupation,  of  iron  and  quinine,  and  a  little  bromide  of  potas- 
sium when  needed. 

In  some  cases  of  delusional  melancholia,  the  delusions  refer  to  ridicu- 
lously paltry  things.  One  young  man,  A.  T.  A.,  once  consulted  me 
on  account  of  his  depressed  condition,  and  the  great  depression  under 
which  he  labored  was  caused,  he  said,  by  his  having  joined  the  Conserva- 
tive Club  in  his  native  town  without  consulting  his  father.  A  woman 
hung  her  depression  on  the  peg  that  the  marriage  ceremony  in  her  case 
many  years  previously  had  not  been  properly  performed  in  some  minute 
particular.  Dozens  of  patients  have  assigned  to  me  as  their  unpardon- 
able sin  that  they  had  occasionally  practised  masturbation.  Patients 
torture  themselves  about  events  in  their  lives  that  no  one  else  can  see  to 
be  of  any  import  whatsoever.  In  some  cases  the  patients  transfer  their 
own  disease  in  delusional  imagination  to  those  near  and  dear  to  them, 
and  are  most  depressed  about  it,  e.  g.^  I  have  a  woman  now  who  says  her 
husband  is  very  ill,  that  he  is  "dull  in  his  mind,  poor  fellow,  and  I  wish 
you  would  cure  him." 

The  following  is  a  case  of  delusional  melancholia,  Avhere  the  delusions 
seemed  at  first  sight  "fixed,"  but  where  recovery  took  place  satisfactorily  : 

A.  U.,  aet.  36.  Disposition  reserved  and  quiet,  but  not  melancholy. 
Nervous  diathesis.     Habits  industrious.      Sister  incurably  insane,  and  is 


STATES    OF    MENTAL    DEPRESSION.  87 

in  an  asylum.  Father  had  an  attack  of  a  month's  duration.  The  ex- 
citing cause  of  the  attack  liad  appeared  to  be  the  death  of  a  near  relation 
of  her  husband,  whom  she  had  helped  to  nurse.  The  first  mental 
symptoms  were  depression  of  spirits  and  sleeplessness.  She  soon  ex- 
pressed the  insane  delusion  that  she  had  been  the  cause  of  her  brother-in- 
law's  death,  through  having  had  improper  thoughts  and  conduct  towards 
him  durino;  his  life.  This  she  talked  of  from  morning;  till  night,  in  fact 
would  speak  of  it  to  strangers,  and  would  talk  of  nothing  else ;  when 
pressed,  her  improper  conduct  was  found  to  have  consisted  in  smoothing 
his  hair  when  he  was  lying  in  bed  very  ill,  and  even  that  may  not  have 
been  a  fact.  She  would  not  employ  herself,  lost  all  interest  in  her  work, 
or  in  anything.  I  saw  her  in  consultation,  and  advised  a  good  trained 
nurse,  change  and  travel,  and  visiting  near  relations.  But  she  got 
steadily  worse,  and  was  very  obstinate  indeed,  and  would  take  no  medi- 
cine. Thinking  that  perhaps  some  uterine  disease  or  disturbance  might 
be  present,  and  determine  the  character  of  her  delusions,  I  wished  her 
examined,  but  she  would  on  no  account  consent.  She  ate  heartily,  and 
looked  fat  and  Avell.  She  made  one  or  two  futile  attempts  at  suicide  by 
twisting  her  hair  round  her  throat.  When  well,  she  had  been  a  bright, 
agreeable  looking  woman ;  when  suffering  from  this  illness,  her  ex- 
pression of  face  was  totally  changed.  One  would  scarcely  have  known 
her  to  be  the  same,  woman.  This  absolute  change  and  reversal  of  the 
characters  of  the  facial  expression  is  most  marked  in  such  melancholia. 
She  had  to  be  sent,  after  about  three  months,  to  one  of  the  villas  attached 
to  the  Asylum,  and  for  the  first  week  she  did  nothing  but  repeat  her  de- 
lusion and  fret  about  it ;  she  thought  of  nothing  else.  She  took  up  the 
idea  then  that  she  ought  not  to  have  left  home  or  come  here.  She  was 
sleepless  and  restless  at  night,  and  very  obstinate.  She  got  tonics,  lived 
in  the  fresh  air,  and  walked  long  distances  each  day  with  her  attendants; 
ate  well,  and  got  forty-five  grains  of  bromide  of  potassium  at  night.  She 
improved  for  three  weeks  and  then  had  a  relapse  during  menstruation, 
which  was  very  abnormally  scanty.  She  felt  as  if  she  had  a  shock  on 
her  head  one  night,  and  after  that  she  felt  as  if  her  brain  was  "  completely 
gone."  Such  neuroses  of  sensibility  are  very  common  in  melancholia, 
and  this  feeling  as  if  the  brain  was  "gone"  is  pai'ticularly  so.  I  suppose 
the  patients  are  conscious  of  a  mental  incapacity,  a  paralysis  of  thinking 
and  volition,  along  with  a  strange  feeling  in  the  head,  and  that  this  is  the 
foundation  of  this  delusion.  After  this  she  changed  somewhat.  She 
was  more  obstinate  and  very  sleepless,  and  unable  to  read  or  employ 
herself;  but,  instead  of  having  caused  her  brother-in-law's  death,  she 
began  to  blame  herself  for  having  left  home  and  her  husband,  and  harped 
on  this  from  morning  till  night,  reproaching  herself  for  what  she  had 
nothing  to  do  with.  I  looked  on  this  change  of  delusion  as  a  very  good 
sign,  and  my  prognosis  was  better  after  that.  She  menstruated  regularly 
but  scantily,  as  she  had  done  from  the  beginning  of  the  attack.  She  was 
put  on  dialyzed  iron,  and  got  it  steadily  thereafter.  In  four  months  there 
was  a  very  great  improvement,  and  in  six  months  she  w^as  well  enough  to 
go  home,  and  completed  her  recovery  there,  having  gained  about  a  stone 
in  weight  during  her  convalescence,  though  she  was  never  thin  from  the 
beginning. 


88 


STATES    OF    MENTAL    DEPRESSION. 


Next  to  the  convulsive  and  organic  varieties  of  melancholia,  the  de- 
lusional is  the  least  hopeful  as  regards  recovery. 

The  folloAving  are  actual  examples  of  delusions  of  about  one  hundred 
female  melancholic  patients,  and  they  far  from  exhaust  the  list : 

Delusions  of  general  persecution. 

"  general  suspicion. 

"  being  poisoned. 

"  being  killed. 

"  being  conspired  against. 

"  being  defrauded. 

"  being  preached  against  in  church. 

"  being  pregnant. 

"  being  destitute. 

"  being  followed  by  the  police. 

"  being  very  wicked. 

"  impending  death. 

"  impending  calamity. 

"  the  soul  being  lost. 

"  having  no  stomach. 

"  having  no  inside. 

"  having  a  bone  in  the  throat. 

"  having  lost  much  money. 

"  being  unfit  to  live. 

"  that  she  will  not  recover. 

"  that  she  is  to  be  murdered. 

"  that  she  is  to  be  boiled  alive. 

"  that  she  is  to  be  starved. 

"  that  the  flesh  is  boilino;. 

"  that  the  head  is  severed  from  the  body. 

"  that  children  are  burning. 

"  that  murders  take  place  around. 

"  that  it  is  wrong  to  take  food. 

"  being  in  hell. 

"  being  tempted  of  the  devil. 

"  being  possessed  of  the  devil. 

"  having  committed  an  unpardonable  sin. 

"  unseen  agencies  workincr. 

"  her  own  identity. 

"  being  on  fire. 

"  having  neither  stomach  nor  brains. 

"  being  covered  with  vermin. 

"  letters  being  written  about  her. 

"  property  being  stolen. 

"  her  children  being  killed. 

"  havino;  committed  theft. 

"  the  legs  being  made  of  glass. 

"  having  horns  on  the  head. 

"  being  chloroformed. 


STATES    OF    MENTAL    DEPEESSION. 


89 


Delusions  of  having  committed  murder. 

"  "  fear  of  beino;  hanged. 

"  "  being  called  names  by  persons. 

"  "  being  acted  on  by  spirits. 

"  "  being  a  man. 

"  "  the  body  being  transformed. 

"  "  insects  coming  from  the  body. 

"  "  rape  being  practised  on  her. 

"  "  having  venereal  disease. 

"  "  being  a  fish. 

"  "  being  dead. 

"  "  having  committed  "  suicide  of  the  soul. 


LECTURE     III. 

STATES  OF  MENTAL  DEPKESSION— MELANCHOLIA 

(P^TCi/^i.G'/yl)— Continued. 

Excited  (Motor)  Melancholia. — This,  like  all  the  other  varieties 
of  the  disease,  may  be  one  stage  in  the  complete  clinical  history  of  a  case, 
or  may  be  the  type  from  beginning  to  end.  The  motor  centres  are 
evidently  affected  to  a  greater  extent  in  this  than  in  any  of  the  other 
varieties,  except  the  one  I  shall  describe  as  the  melancholia  with  epilepti- 
form attacks.  The  patients  rush  about,  are  violent  to  those  about  them, 
wander  ceaselessly,  walking  up  and  down  like  tigers  in  a  cage,  or  roll 
about  on  the  floor,  or  wring  their  hands,  or  shout,  or  groan,  or  moan,  or 
weep  loudly,  or  tear  their  clothes,  or  in  their  cries,  attitudes,  and  motions 
express  strongly  their  mental  pain.  In  short,  the  muscular  expression  of 
the  pervading  emotion  is  strong  and  uncontrollable  by  volition.  Some  of 
the  very  worst  and  most  incurable  cases  of  melancholia  are  of  this  type — 
certainly  the  most  troublesome  to  manage.  The  motor  expressions  are 
pirtly  determined  by  the  intensity  with  which  the  ideo-motor  centres  are 
affected  in  the  brain,  and  partly  by  the  amount  of  inhibition  possessed  by 
the  individual  when  well.  Women  very  frequently  present  the  motor 
type  of  the  disease.  The  Celtic  race  does  so  markedly.  The  wailing 
and  weeping,  the  gesticulations  and  motor  grief  of  an  Irish  woman  are 
usually  out  of  all  proportion  to  the  mental  pain — that  is,  if  we  take  the 
Teutonic  type  as  our  standard.     Here  is  an  example : 

A.  v.,  aet.  28,  an  Irish  woman.  Patient  had  been  confined  a  week 
previous  to  admission.  The  day  before  her  admission  she  suddenly  be- 
came very  unsettled  and  careless  about  her  child ;  she  also  attempted 
suicide.  On  admission  she  was  greatly  depressed ;  she  coiifessed  to 
feeling  exceedingly  miserable,  and  could  only  be  got  to  answer  the 
simplest  questions  with  diflSculty ;  she  had  a  woe-begone  appearance, 
and  her  bodily  health  was  very  weak.  She  slept  very  little  the  first 
night,  but  seemed  considerably  better  next  day :  conversed  readily  and 
cheerfully  ;  said  she  felt  much  better,  and  that  her  strange  behavior  pre- 
vious to  admission  was  due  to  something  which  came  over  her  and  con- 
fused her. 

In  a  week  she  got  worse,  being  much  depressed  ;  thought  she  was  to 
be  killed,  and  that  everything  was  going  wrong  with  her ;  did  not  take 
her  food  well ;  attempted  to  drown  herself  by  jumping  into  the  asylum 
shallow  curling  pond. 

In  a  month  she  was  somewhat  improved,  but  still  continued  much  de- 
pressed in  mind.  She  did  a  little  work.  In  six  weeks,  after  seeming  to 
improve  for  a  time,  patient  relapsed.  She  became  the  embodiment  of 
utter  misery  and  wretchedness,  which  she  exhibited  in  a  most  demonstra- 


STATES    OF    MENTAL    DEPEESSION,  91 

tive  way.  She  wrings  her  hands  ;  sways  backwards  and  forwards,  con- 
torting her  body  ;  rushes  about  from  phice  to  phice,  and  cannot  settle  for 
a  minute.  But  the  most  striking  things  about  her  are  her  countenance 
and  the  noises  she  makes.  She  has  a  large  mouth,  and  as  her  v.sage 
assumes  the  most  doleful  aspect,  expressing  the  intensest  misery,  her 
mouth  begins  to  open  until  it  is  a  great  gaping  cavern,  and  she  howls — 
"Oh,  John,  dear!  doctor,  darlin' !  and  me  childer !  and- me  persecuted 
in  this  jail !  oh,  I'm  punished  !  dear  darlin'  doctor  !  oh,  me  two  brothers  ! 
oh,  kilt  and  murdered  they  are  !  Oh  !  oh  !  oh  !  "  All  this  time  there  is 
seldom  a  tear,  and  it  goes  on  from  morning  till  night,  and  sometimes  all 
night,  so  that  you  cannot  hear  yourself  speak  within  ten  yards  of  her. 
Though  the  misery  is  most  real  to  her,  yet  the  effect  is  often  very  ludi- 
crous, as  if  you  were  looking  at  the  overdone  misery  of  an  Irish  wake  on 
the  stage.  She  ate  well,  and  her  bodily  health  improved,  though  she  had 
prolapsus  uteri,  for  Avhich  no  treatment  could  be  adopted. 

Here  is  a  chronic  case  of  the  sort  that  has  gone  on  for  years : 

A.  W.,  set.  45,  deaf  and  dumb,  who  was  educated.  A  relative  is  in- 
sane. 

For  four  years  now  he  has  been  in  his  present  condition,  which  to  all 
outward  appearance  is  that  of  misery,  as  groat  as  any  painter  has  ever 
depicted  as  the  lot  of  the  damned  in  hell.  He  is  never  at  rest,  but  paces 
about  with  an  uneasy,  nervous  gait.  His  hands  are  always  moving,  tear- 
ing his  clothes  or  unbuttoning  them,  or  mtisturbating,  Avhich  he  does  in 
the  most  shameless  open  way  ;  indeed,  he  is  doing  it  half  the  time.  He 
makes  a  hideous  noise  nearly  all  the  time  between  a  groan  and  a  hiss, 
and  his  expression  of  face  is  that  of  absolute  misery  and  desperation. 
At  times  he  rushes  about,  and  if  any  one  comes  in  his  way  he  knocks 
him  down ;  in  fact,  he  has  a  distinct  homicidal  impulse,  which  makes 
him  attack  those  near  him.  At  times  he  tears  his  flesh  and  beats  his 
head.  He  seems  to  feel  no  pain.  He  is  the  worst  patient  in  Morning- 
side  Asylum,  and,  in  fact,  is  about  the  worst  I  have  ever  seen,  taking  the 
long  time  he  has  been  affected  into  account.  Everything  has  been  tried 
in  vain  for  his  recovery  and  amelioration.  Nothing  will  interest  him ; 
scarcely  anything  will  quiet  him.  I  have  tried  hyoscyamine,  and  it 
nearly  poisoned  him.  I  gave  him  bromide  of  potassium  in  doses  up  to 
six  drachms  a  day.  I  tried  cannabis  Indica  with  it,  and  he  merely  fell 
off  in  flesh,  without  being  benefited.  He  was  walked  in  the  fresh  air  till 
two  strong  attendants  were  done  up.  He  was  tried  to  wheel  heavy  bar- 
rows of  soil,  but  the  fight  to  get  him  to  do  so  threatened  to  run  some 
risk  of  killing  him.  I  only  wish  I  could  castrate  him,  for  the  constant 
masturbation,  or  attempt  to  masturbate,  seems  to  show  that  the  centres 
of  generation  are  in  a  state  of  morbid  excitation,  and  I  think  it  might 
do  him  good. 

This  is  another  chronic  case  of  motor  melancholia,  which  is  very  com- 
mon in  old  age : 

A.  X.,  get.  77.  Single;  gentlewoman.  Disposition  active,  but  pas- 
sionate. First  attack.  No  exciting  cause  known.  Had  a  fall  down 
stairs  six  months  ago.  Became  very  restless  and  sleepless,  and  lost  appe- 
tite.    This  condition  has  lasted  for  three  months. 

On  admission  she  was  very  depressed  and  unsettled.     Could  not  sit 


92  STATES    OF    MENTAL    DEPRESSION. 

down  or  rest  for  a  moment.  Walked  about  the  room  the  picture  of  de- 
spair, and  took  no  interest  in  anything.  Was  enfeebled  in  mind,  and 
behaved  in  a  silly,  miserable  way.  Her  physical  condition  and  general 
health  were  poor,  and  she  was  very  anxious  about  her  state  of  health  and 
her  soul's  salvation.  She  had  no  sleep  the  night  after  admission,  and 
was  very  noisy  and  restless.  She  was  very  depressed ;  begged  to  be 
sent  home ;  wrung  her  hands  and  wept.  This  continued  with  little 
change.  Her  nights,  with  few  exceptions,  were  sleepless,  unless  narcotics 
were  given  ;  and  she  was  also  very  noisy,  beating  at  her  bedroom  door 
and  shouting  loudly.  During  the  day  she  Avas  in  a  constant  state  of 
miserable  unrest.  She  was  suspicious  and  despondent ;  said  she  wished 
she  were  dead ;  refused  her  food ;  would  not  settle  to  any  work.  This 
state  of  unhappy  restlessness  and  excitement  became  fixed  and  chronic, 
while  her  mind  became  more  enfeebled.  She  got  plenty  of  food,  but 
never  could  be  fattened.  After  three  years  she  began  to  show  distinct 
signs  of  partial  hemiplegia,  Avhich  was  first  on  one  side  and  then  on  the 
other,  each  attack  passing  off  in  a  few  days.  Two  of  my  former  assist- 
ants, Drs.  Hayes  Newington  and  J.  J.  Brown,  have  described  this  con- 
dition and  its  pathology,  attributing  it  to  capillary  apoplexies,  as  are 
shown  in  Plate  VII.,  Fig.  2,  occurring  in  succession.^  But  she  could  never 
sit  down  for  a-ny  length  of  time  till  near  the  very  end,  a  year  after  the 
commencement  of  the  paralysis,  when  she  went  to  bed  and  soon  died. 
She  would  eat  her  meals  standing  and  moving.  She  swore  and  used 
blasphemous  language  to  herself.  She  said  she  would  "  burst "  if  she 
was  made  to  sit  down.  The  convolutional  motor  excitement  was  un- 
ceasing, and  nothing  could  exhaust  it.  It  was  connected  with  the  decay 
and  degeneration  and  atrophy  of  the  brain  in  old  age — a  long-continued 
brain  storm  that  ended  only  with  life.  Such  old  people  are  most  difficult 
to  treat.  If  we,  by  mechanical  means,  restrain  their  motions,  my  expe- 
rience has  been  that  it  is  no  conservation  of  energy,  but  the  excitement, 
finding  no  motor  outlet,  reacts  inwards  and  makes  the  mental  state  much 
worse. 

When  insanity  in  boys  and  girls  takes  the  melancholic  form,  it  is 
usually  attended  by  much  motor  excitation,  especially  weeping — the 
boyish  mode  of  expressing  grief.     This  is  an  example : 

A.  Y.,  aet.  12.  Disposition :  old-fashioned,  sedentary,  excitable, 
thoughtful,  and  studious  for  his  age.  Several  brothers  and  sisters  died 
in  infancy  of  head  affections,  and  a  paternal  uncle  had  been  melancholic. 
Mother  nervous  and  eccentric.  Father  died  of  consumption.  Had  been 
brought  up  in  a  poor  way  with  an  old  grandfather,  with  whom  he  lived 
alone,  living  on  tea  and  coffee  and  no  milk.  Had  not  romped  and  played 
enough.  Had  been  in  the  habit  of  wetting  the  bed.  His  father  died  a 
few  months  ago.  Seemed  to  feel  it  as  a  man  would,  and  has  never  been 
the  same  since.  Of  late  has  dreamed  much,  and  awoke  in  the  middle  of 
the  night.  Has  been  at  school,  and  did  well.  Last  week  the  school- 
master checked  him  for  holding  his  pen  the  Avrong  Avay.  He  came  home 
agitated,  nervous,  depressed,  and  confused.  Talked  all  night  in  an  inco- 
herent way  of  holding  the  pen,  etc.     He  has  got  Avorse  till  he  is  now 

^  Edin.  Med.  Journ.,  August,  1874,  and  Journ.  of  Mental  Science,  July,  1877. 


STATES    OF    MENTAL    DEPRESSION.  93 

much  depressed ;  crying,  sometimes  with  tears,  sometimes  without,  all 
the  time.  (By  the  way,  melancholies  are  by  no  means  always  tearless. 
I  have  one  now  who  literally  weeps  floods  of  tears.)  He  was  most  rest- 
less, sleepless,  appetite  gone ;  was  flabby,  with  great  dilated  pupils ;  a 
temperature  of  98°,  and  a  pulse  of  106,  and  weak.  Under  tine,  bella- 
doni^  gtt.  X.  and  potass,  bromid.  gr.  xv.  twice  a  day,  fresh  air,  milk,  and 
light  work,  he  rapidly  improved,  and  was  well  in  a  fortnight.  He  Avets 
the  bed  much  less,  too,  when  well.  But  in  four  months,  when  employed 
as  a  message  boy,  he  began  to  fancy  he  was  dishonest ;  got  confused, 
crying  badly,  was  depressed  and  nervous,  and  dreamed  terrible  dreams. 
He  got  well,  and  then  relapsed.  This  tendency  to  recurrence,  and  re- 
lapse is  characteristic  of  all  the  mental  diseases  in,  and  of  all  the  neuroses 
of,  puberty  and  adolescence.  During  his  first  attack  he  cried,  screamed, 
moaned,  and  groaned,  and  was  most  restless.  In  two  years  from  the 
first  attack,  after  many  relapses,  he  was  sent  to  the  asylum,  and  there, 
under  proper  diet  and  treatment,  he  got  fat  and  cheerful,  making  a  per- 
manent recovery. 

One  gets  a  good  idea  of  excited  motor  melancholia  from  a  case  of 
delirium  tremens,  which,  looked  at  from  a  symptomatological  point  of 
view,  is  a  typical  example  of  this  disease. 

Trophic  affections,  such  as  boils,  skin-itchiness,  and  irritations,  causing 
the  patients  to  pick  their  skin,  tear  out  their  hair,  and  bite  their  nails 
down  to  the  quick,  are  particularly  apt  to  occur  in  the  marked  forms  of 
this  excited  melancholia,  showing  that  the  disturbances  are  profound,  and 
extend  markedly  to  the  trophic  functions  of  the  brain.  For  the  same 
reason,  no  doubt,  some  of  the  cases  are  intractably  prolonged,  and  many 
incurable.  In  no  variety  of  the  disease  do  the  muscular  attitudes  and 
expressions  of  mental  pain  get  so  fixed.  I  have  a  case  now  who  has 
been  melancholic  for  over  twenty  years,  whose  power  of  really  feeling 
mental  pain  has  gone,  but  who  wrings  her  hands  and  groans,  whose 
attitude  is  bent  and  despairing,  and  whose  face  in  deep  furrows  expresses 
the  intensest  melancholy.  This  will  come  on  quite  suddenly,  and  go  off 
as  suddenly,  without  any  outward  cause.  If  interrupted  in  the  middle 
of  one  of  these  attacks  of  agitated  psychalgia,  and  asked — "What's  the 
matter.  Miss  Z.  ?  what  are  you  crying  about?"  she  will  often  smile,  and 
say — "I  don't  know."  "Were  you  unhappy?"  "No."  Or  if  a  glass 
of  wine  or  a  bit  of  cake  is  presented  during  the  midst  of  the  worst 
paroxysm,  she  will  stop  her  groaning,  take  it,  and  smile.  And,  by 
assuming  a  sorrowfiil  or  a  jovial  tone  of  voice,  one  can  make  her  groan 
or  smile,  and  even  sing  a  song.  The  melancholia  has  in  time  become 
muscular  and  automatic,  without  any  real  subjective  feeling  at  all,  and 
there  is  no  memory  of  pain  or  pleasure,  even  for  a  minute.  This  inter- 
esting psychological  condition  is  only  seen  when  the  convolutions  are 
wasted  or  destroyed  structurally.  This  condition  is  often  seen  in  old 
persons.  The  brain  is  more  profoundl}^  disturbed  in  its  functions  in  the 
excited  than  in  any  other  form  of  melancholia,  except  that  with  epilep- 
tiform convulsions. 

Regarding  the  treatment  of  excited  melancholia,  it  might  at  first  sight 
appear  that  mechanical  restraint  of  the  motions  of  such  cases,  or  at  all 
events  narcotic  and  temporarily  paralyzing  drugs,  would  be  indicated  to 


94  STATES    OF    MENTAL    DEPRESSION. 

conserve  the  energy,  and  to  save  exhaustion.  In  former  times,  this  plan 
of  treatment  was  acted  on  habitually.  In  exceptional  cases  we  do  so 
still,  but  a  closer  study  of  the  aftection  and  the  results  of  experience 
show  us  that  evil  results  of  the  gravest  kind  are  apt  to  arise  by  res- 
training the  motions  either  mechanically  or  chemically.  We  see  that 
the  motor  effects  are  the  natural  outcome  and  outlet  of  morbid  energy, 
generated  in  the  brain  ideo-motor  centres.  If  they  are  restrained,  the 
condition  of  the  brain  seems  to  suffer,  the  excitement  to  increase,  and 
there  is  much  greater  risk  of  its  exhausting  and  killing  the  patient,  or 
the  brain  condition  becoming  incurable.  So  we  let  the  patients  walk, 
shout,  and  tumble,  and  we  try  and  send  the  motor  energy  into  normal 
directions  by  much  hard  walking  in  the  open  air,  free  scope,  garden 
work,  wheeling  barrows,  etc. 

I  take  the  following  case  as  a  good  example  of  the  effects  of  such 
rational  treatment  in  motor  melancholia  in  what  was  a  very  severe 
disease,  and  of  the  possibility  of  treating  such  a  case  to  a  favorable  ter- 
mination out  of  an  asylum,  during  the  whole  of  its  course,  when  circum- 
stances are  favorable : 

B.  A.,  set.  60,  a  retired  professional  man,  who  had  been  in  many  cli- 
mates. Temperament  was  sanguine,  diathesis  nervous,  disposition  very 
lively  and  social,  habits  active.  He  once  before  had  a  short  attack  of 
depression,  and  had  recovered  at  home.  The  present  attack  began  by 
simple  depression  and  falling  off  in  weight.  He  then  passed  through  a 
hypochondriacal  stage,  complaining  constantly  of  his  bowels  and  diges- 
tion and  liver.  Those  ideas  increased  until  he  had  fixed  visceral  delu- 
sions. He  had,  as  a  matter  of  fiict,  prolapsus  ani,  but  in  imagination 
his  bowels  were  all  diseased,  and  his  power  of  swallowing  gone.  His 
next  stage  was  that  of  active  motor  excitement,  showing  constant  rest- 
lessness by  night  and.  day — shouting,  tearing  out  his  hair,  and  picking 
his  skin  into  holes.  He  recovered  rather  suddenly  in  about  a  year  from 
the  beginning  of  his  illness,  alter  he  had  gained  about  twenty-eight  pounds 
in  weight.  His  treatment  was  throughout  tonic  and  nutrient — quinine, 
the  mineral  acids,  arsenic,  iron,  the  bitter  natural  waters,  and  strychnine. 
He  took  as  much  as  eleven  tumblers  of  milk  a  day,  and  the  only  thing 
that,  at  one  period  of  his  case,  made  us  not  give  up  hope  was  that  he 
was  able  to  digest  this,  and  that  he  gained  weight,  except  during  the 
most  excited  stage,  which  lasted  for  four  months.  He  took  tr.  cannabis 
indicae  and  bromide  of  potassium  for  the  excitement  with  marked  benefit, 
and  once,  when  he  was  very  excited,  but  improving  in  strength,  I  had 
his  occiput  shaved,  and  a  large  blister  applied,  also  with  benefit.  He 
took  no  animal  food  during  his  illness.  Warm  baths,  with  cold  to  his 
head,  produced  quietude  during  his  excitement.  He  had  a  first-rate 
male  attendant  and  a  devoted  wife,  and  lodged  in  a  suburban  villa,  with 
a  large  garden,  where  he  stayed  nearly  all  day,  driving  and  walking  out 
when  quiet.  I  have  never  treated  a  worse  case  of  melancholia  out  of  an 
asylum. 

Resistive  (Obstinate)  Melancholia. — In  many  cases  of  melan- 
cholia, obstinacy — an  unreasoning,  passive  or  active  resistance  to  any- 
thing that  other  people  want  them  to  do — is  the  marked  feature  of  this 
disease :    to  dressing,  to  undressing,  to  taking  food,  to  going  to  bed,  to 


STATES    OF    MENTAL    DEPRESSION.  95 

getting  ^p,  to  going  out,  to  moving  about,  to  micturating,  etc.  When 
this  resistance  is  very  extreme,  as  it  sometimes  is,  it  is  a  most  difficult 
and  very  dangerous  complication,  from  the  difficulty  of  overcoming  it 
and  carrying  out  necessary  treatment  without  hurting  the  patient.  It  is 
evident,  too,  that  overcoming  the  resistance,  and  making  the  patient  do 
things  contrary  to  his  will,  is  often  attended  with  aggravation  of  his 
mental  pain,  causing  excitement,  and  even  violence.  As  a  general  rule, 
he  cannot  say  why  he  resists;  but  he  does  so  persistently,  doggedly, 
unreasonably,  and  in  some  cases  with  fierce  violence.  It  is  one  of  the 
symptoms  that  try  most  the  patience  of  attendants  and  nurses,  especially 
of  the  less  gentle  and  reasonable  sort.  They  cannot  understand  that  it  is 
a  mere  symptom  of  disease,  and  are  apt  to  treat  it  as  if  it  were  sane  obsti- 
nacy. Resistance  is  sometimes  combined  with  active  motor  agitation, 
but  most  frequently  it  is  passive  obstinacy.  Sometimes  it  is  one  feature 
of  delusional  insanity,  and  the  direct  result  of  the  delusions  present. 
One  patient  cannot  pay  for  his  clothes  or  food,  and  so  will  not  wear  the 
one  or  eat  the  other;  another  fancies  that  she  is  taken  to  execution,  and 
so  will  not  walk ;  another  is  to  be  made  a  spectacle  of,  and  so  will  not 
associate  with  other  patients.  Some  have  vague  feelings  of  distress  that 
the  house  is  falling,  and  that  the  ground  is  unsteady,  and  so  will  not 
move.  One  most  resistive  woman  I  have  now  as  a  patient — B.  B. — who 
will  not  do  anything  that  is  good  for  her.  She.  will  not  put  on  her 
clothes  or  shoes,  and  says,  in  a  vague,  fearful  way — "  It's  awful  [this 
is  a  most  common  expression  among  certain  melancholies].  I'm 
trampling  myself  down  under  the  ground  [and  so  she  will  not  walk]. 
I'm  in  a  hole  to  serve  other  people.  I've  neither  meat  nor  drink  [she 
had  both  before  her,  but  in  regard  to  those  she  had  not  the  sweet  sense 
of  possession].  I  dinna  ken  the  beginning  o't,  and  I  dinna  ken  the 
end  o't.  I  never  thocht  I  was  to  be  the  key  o'  the  earth.  Everything's 
naething.  I've  come  miles  and  miles.  It's  awfu'.  I  was  forty  when 
they  changed  me  into  this  state.  I  dinna  ken  what  age  I  am  now. 
They've  greased  me  a',  and  gin  me  oil  [castor-oil],  and  done  a'  kinds 
o'  things,  and  there's  no  a  bit  o'  wit  in  me."  She  shoAvs  that  there  is 
some  delusional  doubt  in  her  mind  as  to  her  own  personal  identity,  as  to 
the  ground  on  which  she  stands,  as  to  time  and  space,  and  as  to  her  own 
age;  and  she  attributes  all  the  bad  feelings,  etc.,  to  what  others  have 
done  to  her.  Her  courage,  sensibility,  and  muscular  sense  are  perverted. 
Extreme  obstinacy  in  cases  of  melancholia  is  usually  the  result  of  a  com- 
plicated and  deep  delusional  state  such  as  this,  in  my  experience,  or  to 
an  insane  stupidity,  confusion  of  mind,  and  want  of  power  of  compre- 
hension or  attention.  There  is  an  element  of  stupor  in  some  of  them, 
but  usually  of  delusional  stupor.  One  may  not  at  the  time  be  able  to 
make  out  what  the  delusions  are,  but  patients  can,  after  recovery,  usually 
tell  what  they  were.  In  some  of  these  cases,  I  am  reminded  of  the  re- 
sistance of  a  wild  animal,  or  the  behavior  of  certain  savages,  when  first 
caught.  Fear,  the  instinct  of  self-preservation,  unreason,  suspicion,  and 
the  instinct  of  freedom  are  all  mixed  up  in  the  case.  An  evolutionist 
would  have  no  difficulty  in  seeing  in  those  phenomena  a  reversion  to 
primitive  instincts.  I  have  often  seen,  as  clinical  accompaniments  of 
such  cases,  a  hot-feeling,   perspiring  skin   and  a  particularly  ofiensive, 


S6  STATES    OF    MENTAL    DEPRESSION". 

strongly  smelling  perspiration.  Women  have  often  greater  men|al  con- 
fusion and  obstinacy  at  the  menstrual  periods.  Masturbation  in  both 
sexes  often  causes,  aggravates,  and  accompanies  this  condition.  They 
often  admit  afterwards  that  it  was  this  habit  which  aggravated  their 
confusion  and  obstinacy  during  the  illness,  but  say  that  it  was  almost 
involuntary  and  automatic  at  the  time.  I  have  now  a  lady — B.  C. — 
under  my  care,  whose  obstinacy  is  so  extreme  that  it  sometimes  takes 
six  attendants  to  dress  her,  yet,  when  the  first  article  of  clothing  is  put 
on,  she  will  sometimes  finish  her  dressing  herself  A  locked  door  makes 
her  furious  to  open  it,  so  we  allow  her  to  go  where  she  likes,  and  almost 
do  what  she  likes.  She  will  stand  in  a  passage  for  hours,  evidently 
uncertain  what  to  do,  but  any  attempt  to  make  her  go  one  way  will  cer- 
tainly tend  her  to  go  the  other  with  all  her  might.  When  opposed,  she 
is  fiercely  resistant,  attacking  those  about  her  most  violently  at  times. 
Resistance  to  taking  food  in  such  cases  is  most  common,  and  most  pre- 
judicial to  their  recovery.  They  are  unpersuadable,  but  sometimes  when 
the  fiyst  mouthful  is  forced  into  their  mouths,  they  will  then  finish  the 
meal.  In  other  cases,  if  food  is  left  near  them  in  an  out-of-the-way 
place,  they  will  go  and  eat  it  by  stealth,  denying  the  fact  afterwards. 
We  often  take  advantage  of  this  peculiarity  to  get  them  to  take  food. 
In  some  of  those  things  they  are  exactly  like  a  wild  animal  beginning 
to  be  tamed. 

This  condition  sometimes  has  more  of  confusion  and  stupidity  than 
resistance  or  obstinacy,  and  when  that  is  so,  it  is  allied  to  melancholic 
stupor,  of  which  I  shall  speak  in  another  lecture.  In  fact,  I  have  seen 
resistive  melancholia  a  stage  in  a  case  passing  into  stupor,  and  then 
again  a  further  stage  in  passing  out  of  it  towards  recovery. 

The  following  was  a  prolonged  case  Avho  recovered :  B.  D.,  set.  40. 
Married.  Temperament  bilious;  diathesis  nervous;  disposition  cheerful; 
habits  active.  No  children.  First  attack:  duration  eleven  months. 
Assigned  cause,  depression  from*  diarrhoea.  Faint  symptoms  at  first, 
suggesting  epilepsy,  but  no  true  convulsion.  Her  father  was  epileptic, 
and  a  sister  insane.  She  became  depressed,  and  refused  food,  requiring 
the  use  of  the  stomach-tube  for  two  months.  Had  delusion,  e.g.,  that 
her  husband  w^as  near  her  when  he  was  far  away.  At  first,  she  was 
treated  in  a  private  house,  but  her  extreme  obstinacy  about  eating, 
dressing,  undressing,  walking  out,  and  coming  home  when  out,  implied 
more  attendance  at  times  than  could  be  got  in  any  private  house.  Was 
afterwards  sent  to  an  asylum.  She  there  took  her  food,  and  slept  well, 
but  was  full  of  delusions  as  to  her  husband  and  friends  being  in  the  insti- 
tution.    She  was  very  obstinate,  dissatisfied  and  unsociable. 

On  admission  to  Morningside  Asylum,  she  was  found  to  be  laboring 
under  melancholia,  and  to  be  in  fair  bodily  health.  Two  months  after 
admission,  it  is  noted:  "B.  D.  continues  very  restless  and  obstinate,  and 
it  is  with  difiiculty  she  can  be  got  to  do  anything.  She  occasionally 
plays  on  the  piano,  but  only  does  so  to  get  a  newspaper,  which  she 
seldom  reads,  but  carries  about  with  her,  and  will  not  give  up  again, 
believing  it  contains  messages  from  a  friend.  There  is  no  active  excite- 
ment or  any  other  symptom — simply  passive  resistance  to  almost  every- 
thing.    She  constantly  imagines  that  some  relative  of  hers  has  come  to 


STATES    OF    MENTAL    DEPRESSION.  97 

see  her,  and,  when  out  walking,  will  look  into  all  sorts  of  improbable 
places  for  this  person.  She  sleeps  fairly  at  nights,  but  awakes  very 
early  in  the  morning,  and  is  then  very  restless.  Takes  her  food  well ; 
gets  tonics  of  all  sorts."  Continued,  after  eighteen  months,  as  restless 
and  obstinate  as  ever,  and  could  not  be  got,  without  much  trouble,  to  do 
any  work.  Slept  badly,  and  was  often  restless  at  night.  Took  plenty 
of  food,  and  kept  in  fair  bodily  health.  But  little  doubt  she  was  ad- 
dicted to  masturbation,  and  was  the  worse  for  it.  Looked  sometimes 
very  demented,  and  could  not  be  got  to  do  much  work.  Slept  rather 
better.  Took  plenty  of  food.  Prognosis  seemed  very  doubtful.  During 
the  latter  half  of  the  second  year,  she  was  able  to  go  out  on  pass  on 
several  occasions;  and  in  the  end  of  it,  she  was  more  settled  and  tidy 
in  her  ways,  but  still  full  of  the  delusions  about  people  being  present 
who  were  not,  etc. 

In  three  years,  after  various  trips  to  the  seaside,  and  a  tour  in  the 
Highlands,  she  had  improved  sufficiently  to  leave  the  asylum  on  a  year's 
probation,  going  first  to  live  in  a  family  for  a  year,  then  taking  a  tour  on 
the  Continent,  and  finally  being  able  to  take  up  housekeeping  for  her- 
self, and  getting  rid  of  every  trace  of  her  mental  disease,  becoming  very 
stout,  healthy,  and  cheerful  after  about  five  years  from  the  commence- 
ment of  her  attack. 

This  case  shows  that  treatment  should  be  continued,  and  hope  should 
not  be  given  up  for  a  long  time  in  such  a  patient. 

The  following  is  probably  an  incurable  case :  B.  E.,  set.  46.  Single. 
Education  good ;  disposition  cheerful ;  habits  active  and  industrious.  No 
known  hereditary  predisposition  to  insanity.  First  attack:  duration, 
two  months ;  predisposing  cause,  change  of  life.  She  became  depressed, 
and  had  melancholic  delusions,  e.g.,  that  she  had  committed  some  crime, 
and  must  be  punished;  complained  of  headache,  neuralgia,  and  uterine 
disorder.  *  , 

On  admission,  she  had  a  look  of  stolid  misery ;  was  evidently  much 
depressed  in  spirits;  was  very  obstinate  and  intractable;  refused  her 
food;  was  very  taciturn,  and  showed  a  good  deal  of  motor  excitement. 
Her  physical  condition  was  poor,  but  there  was  no  organic  disease. 

From  the  beginning,  there  was  the  greatest  difficulty  in  nourishing 
her,  and  for  nearly  ten  months  the  nose-tube  had  to  be  used  regularly. 
She  resisted  the  operation  of  feeding  in  the  most  obstinate  and  dogged 
manner,  the  services  of  some  half-dozen  attendants  being  usually  re- 
quired before  a  meal  could  be  given.  In  the  same  manner,  she  resisted 
being  dressed,  undressed,  taken  out  for  exercise,  going  to  the  water- 
closet,  or  leaving  it  when  there.  Her  resistance  w^is  not  passive,  but 
very  active  indeed;  she  would  often  strike  and  kick  those  who  wished 
to  make  her  go  out,  and  she  would  seize  hold  of  anything  near,  and 
nothing  but  force  would  overcome  her  resistance.  She  behaved  in  a  way 
trying  to  the  patience  of  all  concerned.  About  five  months  after  ad- 
mission, she  sustained  a  fracture  of  the  right  ulna — an  accident  evidently 
due  to  the  force  required  to  overcome  her  resistance.  Two  months 
after  admission,  a  haematoma  was  observed  in  left  ear,  and  was  blistered 
with  advantage. 

Her  condition  improved  considerably  for  a  few  months,  and  the  nose- 

7    ■ 


98  STATES    OF    MENTAL    DEPRESSION. 

tube  was  dispensed  with.  She  gained  in  weight,  did  a  little  useful  work, 
and  at  times  talked  rationally  and  cheerfully.  This  improvement,  how- 
ever, did  not  persist,  and  eighteen  months  after  admission,  she  was  in 
the  following  very  unsatisfactory  condition :  She  is  with  great  difficulty 
made  to  take  her  food.  She  is  very  irritable,  obstinate,  and  wayward. 
She  constantly  desires  to  do  what  she  ought  not  to  do,  and  she  Avill  not 
do  what  she  ought  to  do.  She  takes  no  intelligent  or  cheerful  interest 
in  anything;  she  sometimes  uses  very  bad  language;  she  complains 
peevishly  when  asked  to  do  anything;  then  if  told  she  must  not  do  it, 
says  she  must;  she  is  full  of  discontent  and  peevishness,  but  will  do 
nothing  herself  or  for  herself,  standing  looking  in  a  helpless  way,  as  if 
tied  to  the  spot,  saying — "Don't  let  them  put  me  out,"  or  "bring  me 
in,"  as  the  case  may  be.  There  are  paralysis  of  volition,  depression, 
inattention  to  the  calls  of  nature,  active  resistance,  and  increased  mental 
pain  when  her  resistance  is  overcome  by  force.  The  prognosis  is  bad 
now  after  two  years.  Dirty  habits  developed  eighteen  months  after  the 
commencement  of  the  attack.  A  haematoma  in  such  a  case  is  almost 
sufficient  to  warrant  a  verdict  of  incurability. 

Melancholia  with  Epileptiform  Attacks  (Convulsive  Melan- 
cholia).— In  the  excited  form  of  melancholia,  the  motor  movements  are 
ideo-motor  and  volitional — that  is,  coordinated  motions  and  indications 
of  emotional  depression  without  necessary  loss  of  consciousness  and 
memory.  But  in  the  form  I  am  now  to  describe,  the  motor  affection  is 
a  true  convulsion  with  unconsciousness,  occurring  once  or  twice,  seldom 
often,  in  the  course  of  the  attack ;  and  it  differs  in  no  way  in  some  cases 
from  an  ordinary  epileptic  fit,  and,  in  others,  in  no  way  from  a  general 
paralytic  epileptiform  attack.  It  is  a  true  epilepsy  in  Hughlings  Jack- 
son's sense.  This  form  of  melancholia  has  not  been  described,  though 
it  is  in  my  opinion  the  most  serious  variety  of  the  disease.  In  it  the 
whole  of  the  functions  of  a  br^in  convolution  are  affected — mental, 
motor,  sensory,  trophic,  and  vaso-motor.  The  mental  depression  is  very 
intense,  accompanied  by  muscular  agitation  and  excitement,  and  usually 
by  great  obstinacy.  There  are  usually  much  insensibility  to  pain  and  a 
tendency  to  skin  irritations,  so  that  the  patients  scratch  themselves,  and 
pick  holes  in  their  skin,  or  rub  off  their  hair,  or  pull  it  out  in  patches. 
They  are  all  prolonged,  and  practically  incurable,  for  I  have  seen  only 
two  make  even  modified  recoveries,  and  none  of  them  have  ever  been 
able  to  work  afterwards.  It  must  be  understood  that  I  do  not  include 
in  this  variety  convulsions  of  syphilitic  or  alcoholic  origin.  They 
are  present  in  certain  cases  of  those  two  kinds  of  insanity,  but  I  shall 
refer  to  them  under  those  headings.  This  variety  of  melancholia  has  a 
pretty  distinct  pathology  too.  I  have  never  met  with  any  case  where, 
after  death,  some  limited  adhesion  of  the  pia  mater  to  the  convolutions 
was  not  found,  just  as  in  general  paralysis;  but  this  was  not  found  at 
the  vertex,  but  on  some  of  the  basal  convolutions.  The  structure  of  the 
convolutions  is  altered  on  microscopic  examination,  there  being  prolifera- 
tion of  the  nuclei  of  the  neuroglia,  especially  seen  around  the  arterioles 
and  capillaries,  with  destruction  of  many  of  the  nerve-cells.  If  my 
views  in  regard  to  the  special  pathological  entity  of  general  paralysis 
had  not  been  so  definite,  I  should  have  been  tempted,  in  looking  at  the 


STATES    OF    MENTAL    DEPEESSION.  99 

brain  lesions  in  some  of  these  convulsive  cases,  to  have  regarded  the 
disease  as  an  exceptional,  localized,  non-progressive,  general  paralysis. 
But  that  would  be  pathological  nonsense.  One  might  as  well  talk  of  a 
non-febrile  typhoid  fever. 

The  convulsive  attacks  in  these  cases  are  very  rare,  only  occurring 
once  or  twice  or  thrice  in  the  course  of  many  years.  Sometimes  the 
convulsion  is  prolonged,  lasting  for  half  an  hour,  with  hours  of  uncon- 
sciousness, and  a  high  temperature  afterwards,  as  in  general  paralysis. 
In  other  cases,  the  fit  seems  like  a  sporadic  attack  of  ordinary  epilepsy. 
I  have  seen  over  a  dozen  of  these  cases,  but  of  eight  I  have  records, 
since  I  realized  that  this  was  a  distinct  clinical  and  pathological  variety 
of  melancholia — almost  the  only  variety  that  can  be  correctly  so  de- 
scribed. Inasmuch  as  it  is  so,  it  ought  properly  to  have  come  under  the 
forms  of  mental  disease  in  the  clinical  classification,  but  I  think  it  more 
convenient  and  instructive  to  bring  it  in  here.  Of  those  eight  cases, 
five  had  only  one  epileptiform  attack ;  two  had  two,  and  one  had  many. 
In  six,  they  happened  within  three  months  of  the  beginning  of  the  dis- 
eases; in  one,  after  three  years,  and  in  one  only  after  twenty  years.  In 
three  of  them,  the  patients  died  within  three  years ;  in  five,  they  have 
lived — one  for  twenty-one,  one  for  seven,  two  for  six,  and  one  for  five 
years,  and  show  no  sign  of  dying.  They  differ  entirely  from  ordinary 
epileptics,  and  from  the  cases  with  occasional  epileptic  fits  that  sometimes 
occur  in  advanced  dementia,  as  the  brain  gets  wasted. 

The  following  are  examples  of  this  form  of  melancholia : 

B.  F.,  set.  61.  Single.  Temperament  melancholic.  Education  good ; 
disposition  cheerful,  with  periods  of  irritability;  habits  perfectly  steady; 
teetotaller.  One  previous  attack  of  melancholia.  Hereditary  predis- 
position to  insanity ;  cause  unknown.  The  attack  began  by  a  running 
down  of  bodily  health  generally.  Duration  of  existing  attack,  three  or 
four  months.  Has  been  depressed,  and  lately  has  had  two  epileptiform 
seizures,  each  lasting  about  five  minutes.  '  Attempted  to  cut  his  throat 
the  day  before  admission. 

On  admission  was  very  depressed,  and  had  many  melancholy  delusions. 
Said  that  he  had  lost  all  his  money  and  was  entirely  ruined,  that  he  was 
hundreds  of  pounds  in  debt,  and  that  he  can  never  pay  what  he  owes. 
He  was  taciturn,  obstinate  and  reticent,  and  displayed  considerable 
impairment  of  memory.  He  was  in  feeble  health,  and  had  kidney  and 
liver  disorder. 

The  prominent  feature  in  this  case  is  a  curious  unreasoning,  automatic 
obstinacy.  When  dinner  is  announced,  for  example,  no  persuasion  will 
get  him  to  go  down  to  the  dining-room ;  and  when  requested  to  go  out  to 
walk  he  simply  will  not  go.  He  can  give  no  reason  for  his  refusal,  and 
when  force  is  used  he  resists  with  all  his  strength.  In  other  respects  he 
behaves  in  a  very  quiet  and  sedate  manner.  He  is  a  very  diligent 
reader,  wakening  up  to  activity  when  fresh  newspapers  or  periodicals  are 
brought  in.  He  is  usually  little  given  to  conversation,  and  he  is  slow  to 
reply  to  any  observation  made  to  him.  He  is  still  very  despondent, 
believing  that  he  is  ruined,  and  that  he  has  not  a  penny  of  his  own,  but 
he  has  occasional  outbursts  of  fun,  and  even  plays  little  practical  jokes  at 
times,  and  laughs  at  the  result.     Now  and  then  he  will  talk  as  animatedly 


100  STATES    OF    MENTAL    DEPRESSION. 

and  intelligently  about  things  as  ever  he  did  in  his  life,  and  one  could  not 
tlien  say  there  was  anything  wrong  with  him.  Yet,  in  the  midst  of  this, 
if  his  dinner  is  announced,  or  the  time  comes  to  go  out  to  walk,  he  will 
become  confused  and  obstinate,  and  will  need  to  be  taken  out  of  the  room 
by  force,  no  amount  or  kind  of  persuasion  at  all  availing.  He  has  now 
been  six  years  insane.  He  had  no  more  epileptiform  seizures,  but  does 
not  improve  or  change  mentally. 

This  was  a  case  of  convulsive  melancholia  which  became  chronic  and 
incurable,  with  muscular  expressions  of  mental  pain,  but  no  real  feeling. 
Enfeeblement  of  mind  ;  two  epileptiform  attacks — one  twenty  years  before 
the  other. 

B.  H.,  aet.  36,  when  admitted  labored  under  melancholia.  Had  been 
treated  in  the  asylum  ten  years  before,  and  had  recovered.  Insanity 
supposed  to  be  due  to  too  free  use  of  stimulants.  After  eight  years' 
residence  she  was  discharged  improved,  but  within  three  years  she  was 
brought  back.  She  was  greatly  excited — crying,  moaning,  wringing  her 
hands,  and  displaying  generally  a  picture  of  the  most  intense  misery,  and 
had  an  epileptiform  tit  soon  after  admission. 

She  has  now  been  for  twenty-one  years  in  a  condition  of  melancholia ; 
but  with  the  lapse  of  time  her  feelings  have  become  so  blunted,  and  her 
intellectual  faculties  so  dull,  that  while  she  still  wears  all  the  trappings 
and  the  suits  of  woe,  her  face  drawn  and  furrowed,  and  in  a  fixed  state 
muscularly  of  utter  misery,  her  attitude  that  of  utter  dejection,  and  con- 
stantly wringing  her  hands  and  uttering  a  sound  between  a  wail  and 
a  groan — she  is  inwardly,  if  not  happy,  at  least  free  from  real  conscious 
remembered  mental  pain.  For  about  two  days  in  each  week  she  is 
wonderfully  bright  and  sensible.  At  other  times  she  is  very  stupid  and 
helpless.  At  her  best  she  is  much  enfeebled  in  mind,  and  is  childish  and 
forgetful.  She  rubs  the  hair  off  parts  of  her  head  incessantly,  and  often 
for  hours  she  calls  out — "Oh  dear!  oh  dear!"  in  the  most  doleful  tones. 
But  when  asked  if  she  is  unhappy,  she  smiles  and  says — "  Oh,  no; "  and 
she  will  chat  away  in  a  pleasant,  garrulous  manner,  and  will  sing  a  snatch 
of  a  song  or  play  a  tune  on  the  piano,  or  beg  for  a  bit  of  cake.  She  says 
she  cannot  help  looking  so  miserable,  and  suggests  that  it  may  be  due  to 
her  having  a  corn  on  her  foot.  She  likes  to  be  taken  notice  of  and 
is  grateful  for  attentions,  and  often  shows  an  amount  of  childish  wonder 
and  interest  in  little  occurrences.  She  had  a  general  epileptiform  seizure 
in  1880,  twenty-one  years  after  the  first,  the  second  in  the  course  of  her 
disease. 

Organic  Melancholia  (the  Melancholia  Accompanying  Gross 
Organic  Brain  Disease). — I  think  the  epileptiform  variety  of  melan- 
cholia is  analogous,  from  an  etiological  and  pathological  point  of  view,  to 
that  form,  often  only  amounting  to  depression  of  spirits,  which  very  com- 
monly accompanies  coarse  organic  disease  of  the  brain,  tumors,  softenings, 
and  wastings.  It  is  usually  in  the  first  stages  of  those  diseases  that  we 
have  the  mental  depression,  though  in  some  cases  it  continues  till  death. 
In  some  of  those  cases  I  have  seen  the  mental  symptoms  tlie  very  first  to 
appear,  long  before  the  paralysis  or  even  before  great  bodily  weakness 
made  its  appearance.  A  paralysis  of  the  sense  of  well-being  and  the 
enjoyment  of  life,  a  difficulty  in  coming  to  decisions,  a  loss  of  mental 


STATES    OF    MENTAL    DEPRESSION.  101 

energy,  an  intolerance  of  the  usual  work,  if  not  an  actual  incapacity  to 
do  it  well,  a  tendency  to  make  slight  mistakes  in  small  things,  a  loss  of 
memory,  and  a'  subacute  mental  pain,  I  have  seen  exist  for  two  years 
before  a  man  showed  any  diagnostic  signs  of  brain  ramollissement  or 
tumor.  The  melancholia  is  usually  of  the  simple  type,  seldom  assuming 
the  excited,  delusional,  or  distinctly  suicidal  form.  I  have  seen  it  of  the 
hypochondriacal  kind  in  a  few  cases.  Organic  melancholia  commonly 
ends  in  organic  dementia  as  the  brain  disease  progresses,  if  the  patient 
lives  long  enough.  But  the  patients  seldom  need  to  be  sent  to  lunatic 
asylums  if  they  have  money  enough  to  pay  for  home  nursing  and 
attendance. 

The  following  is  a  typical  case  of  organic  melancholia,  interesting 
from  the  bodily  as  well  as  from  the  mental  point  of  view : 

B.  J.,  aet.  35.  Melancholic  temperament,  nervous  diathesis,  cheerfiil 
disposition,  and  most  industrious  habits.  An  unusually  intelligent  man, 
who,  after  his  business  hours  (and  they  were  long  and  hard),  read  con- 
tinuously books  on  philosophy  and  science.  There  was  no  known 
heredity  to  mental  or  brain  disease.  He  had  mental  worry  and  business 
disappointment,  with  a  weariness,  lassitude,  and  loss  of  energy.  The 
disease  began  by  his  being  forgetful  of  things.  This  he  was  conscious  of, 
and  it  worried  and  depressed  him,  and  from  some  expressions  he  used 
his  friends  feared  suicide.  He  had  at  the  same  time  headaches,  then  he 
felt  bad  smells  where  none  existed  (a  grave  symptom  ahvays),  then  he 
began  to  take  short  unconscious  attacks,  Avithout  convulsion  or  falling 
down,  sometimes  several  times  a  day. 

When  I  saw  him  first,  eight  months  after  the  symptoms  had  begun,  he 
was  depressed,  but  without  any  intellectual  delusion.  He  could  not  read 
or  apply  himself  to  anything ;  his  memory  was  bad ;  he  had  terrible 
headaches,  and  a  feeling  of  a  band  round  his  head;  his  head  was  not 
pained  by  tapping  with  the  finger ;  his  right  face,  arm,  hand,  and  leg 
were  weaker  than  the  left,  and  he  had  a  peculiar  slow  mode  of  speech,  a 
difficulty  in  remembering  words,  and  a  tendency  to  use  wrong  words 
having  the  same  general  sound  to  those  he  wished  to  use.  Sexual  desire 
and  capacity  had  ceased  for  six  months.  He  was  constantly  sleepy  and 
yawning,  and  would  go  to  sleep  as  he  sat  and  talked  to  one ;  in  fact,  all 
the  time  he  seemed  like  a  man  half  asleep  (a  grave  symptom  too).  He 
had  a  perpetual  weariness.  Face  very  heavy  and  expressionless.  When 
very  bad  one  day,  and  he  wanted  to  say  that  he  never  had  a  foul  tongue, 
he  said — "I  never  was  like  some  folks  that  show  that  they  have  a  strong 
color  on  the  tone — on  the  tongue."  His  bowels  were  excessively  costive. 
My  diagnosis  was  serious  brain  disease  affecting  the  convolutions,  but 
chiefly  confined  to  the  left  side.  I  thought  it  might  be  softening  or 
tumor.  In  case  it  might  be  of  syphilitic  origin,  and  also  because  I  had 
found  this  treatment  gave  relief  in  cases  of  this  kind  of  non-specific 
origin,  I  put  him  on  large  doses  of  the  bromide  and  iodide  of  potassium, 
with  one-twelfth  grain  doses  of  corrosive  sublimate.  I  also  blistered  his 
head  severely  behind.  This  treatment  undoubtedly  relieved  the  intensity 
of  the  pain,  and  stopped  the  unconscious  epileptiform  attacks.  His  tem- 
perature at  this  stage  was  subnormal,  seldom  exceeding  97°.  In  three 
weeks  after  I  saw  him  he  had  got  distinctly  worse.     He  walked  worse, 


102  STATES    OF    MENTAL    DEPRESSION. 

staggered,  and  would  fall  backwards  and  to  the  right  if  left  alone.  He 
spoke  worse,  and  wrote  worse,  e.  g.,  when  I  asked  him  to  write  "'my 
hat,"  which  was  before  him,  he  wrote  slowly  ^^mhate."  His  temperature 
was  100°  in  the  evening.     He  died  suddenly  next  morning. 

On  2)ost-mortem  examination,  I  found  on  removing  the  dura  mater 
that  the  convolutions  bulged,  and  were  flattened  especially  on  left  side. 
The  whole  of  the  middle  lobe  of  left  side  felt  baggy  and  fluid  on  pressure. 
On  section  the  lateral  ventricle  of  that  side  was  enlarged,  and  almost  all 
the  white  substance  of  that  lobe  was  gelatinous,  stringy,  with  a  pale 
straw-colored  fluid  oozing  from  it.  It  was,  in  some  respects,  unlike 
any  case  of  brain  softening  I  had  ever  seen.  The  gray  matter  forming 
the  gyri  of  the  middle  lobe  was  pale  and  soft,  but  not  difiluent  or  gela- 
tinous. The  pia  mater  stripped  off"  it  very  readily.  The  corpus  striatum 
and  optic  thalamus  of  that  side  were  softened  to  some  extent.  I  could 
find  no  embolism  or  thrombosis  of  any  of  the  arteries  to  account  for  the 
softening.  The  anterior  and  posterior  lobes  were  pale,  and  wanting  in 
consistence,  but  not  gelatinous.  Broca's  convolution  was  not  greatly 
affected.  The  right  hemisphere  was  pale  and  soft,  especially  the  whole  of 
the  central  white  substance,  but  was  not  gelatinous  like  the  left.  In  the 
pons  just  under  the  floor  of  the  fourth  ventricle,  was  a  small  recent 
apoplexy,  the  size  of  a  split-pea. 

None  of  the  current  vascular  or  embolic  theories  explains  such  a  case 
of  brain  softening.  I  think  such  a  disease  is  the  result  of  morbid  trophic 
changes  of  purely  nervous  origin,  and  independent  of  the  blood  supply. 
Some  of  the  modern  authorities  would  apparently  deny  to  the  nerve  tissue 
an  inherent  power  to  waste  or  disintegrate,  or  to  become  diseased  indepen- 
dently of  the  blood  supply  or  the  packing  tissue  changes.  I  believe  in 
no  such  theory.  Over-mental  work  does  not  directly  afiect  the  blood- 
vessels, yet  it  causes  brain  changes  of  the  most  serious  kinds.  Even 
when  vascular  changes  are  found,  I  believe  them  to  be  secondary  in  great 
measure  to  the  alterations  of  nervous  structure.  The  bloodvessels  and 
the  neuroglia  are,  after  all,  the  servants  of  the  brain  tissue  proper,  and 
this  has  not  been  kept  sufficiently  in  mind  in  recent  nerve  pathology. 

On  the  vascular  starvation  theory  of  brain  necrosis  it  has  been  always 
assumed  that  some  mechanical  obstruction  of  a  vessel  by  embolism  or 
thrombosis  is  required.  I  have  seen  most  of  a  hemisphere  softened  and 
bloodless,  with  every  vessel  folly  patent.  There  had  evidently  been  a 
spasmodic  closure  of  the  vessels,  a  true  vaso-motor  spasm  of  a  prolonged 
and  complete  kind,  starving  one  hemisphere  of  blood  and  killing  the 
patient.  I  believe  that  frequently  happens,  and  is  the  cause  of  soften- 
ings, epilepsies,  spasms,  and  mental  affections  in  different  cases. 

Such  a  case  is  a  type  of  dozens,  more  or  less  like  it,  that  I  have  seen 
in  consultation,  and  that  most  practitioners  in  medicine  have  seen.  It  is 
most  instructive,  as  showing  that  the  mental  ftmctions  of  the  brain  were 
first  to  show,  by  their  disorder,  that  the  organ  was  beginning  to  be  dis- 
eased, and  that  mental  depression  was  one  marked  early  symptom  of  the 
incipient  trophic  changes  in  the  tissues.  They  confirm  strongly  my  idea 
that  mental  depression,  per  se,  is  simply  the  functional  expression  of  con- 
volutional  malnutrition. 


STATES    OF    MENTAL    DEPRESSION.  103 

The  following  is  an  interesting  case  in  a  more  acute  form,  with  chiefly 
convolutional  disease,  and  no  such  extensive  ramollissement  as  the  last: 

B.  K.,  aet.  39.  Single.  Clerk.  Disposition  very  cheerful,  frank, 
and  social ;  habits  quiet  and  industrious  ;  doubtfully  temperate  ;  no  pre- 
vious attack  ;  sister  insane.  Has  had  indigestion  for  years,  and  has  led 
a  veiy  sedentaiy  life.  Two  years  ago  a  change  in  his  behavior  was  first 
noticed,  and  for  the  last  six  weeks  he  has  been  very  depressed  and  unfit 
for  work.  Thought  that  he  was  a  wicked  man,  that  he  had  ruined  his 
friends,  and  that  he  was  going  to  die.  Has  been  sleepless  ;  has  refused 
food ;  has  fallen  off"  greatly  in  weight ;  and  has  complained  of  constipa- 
tion. 

On  admission  is  in  a  state  of  great  depression ;  says  he  cannot  live 
over  twenty-four  hours,  and  that  he  is  utterly  ruined  in  soul  and  body, 
and  one  of  the  greatest  sinners  in  existence.  Is  restless,  unsettled,  and 
comfortless ;  cannot  sit  still  for  a  moment.  Complains  of  obstinate  con- 
stipation ;  is  unsteady  in  his  walk  ;  articulation  is  spasmodic  and  falter- 
ing ;  left  pupil  is  larger  than  right ;  left  side  of  face  is  flatter  than 
right ;  there  are  occasional  twitches  in  the  facial  muscles ;  reflexes  im- 
paired. 

Slept  well  first  night,  but  little  afterwards.  Took  plenty  of  food. 
Bowels  cleared  out  with  magnes.  sulph.  and  an  enema.  Two  days  after 
admission  he  had  a  severe  general  convulsive  seizure,  with  loss  of  con- 
sciousness. Consciousness  was  regained  in  a  few  minutes,  and  shortly 
afterwards  he  became  considerably  excited,  talking  in  a  confused,  excitedly 
delusional  way  about  "Her  Majesty,"  "her  message,"  "the  Queen 
coming,"  "  the  soldiers,"  etc.  Was  sent  out  for  an  hour's  walk ;  was 
then  given  a  draught  of  chloral  and  bromide  of  potassium,  and  was 
put  in  bed  in  a  dark  room.  Slept  well  for  two  and  a  half  hours,  and 
since  then  has  been  quiet,  and  depressed  as  on  admission.  This  is  a 
mode  of  cutting  short  the  mental  excitement  after  an  epileptic  attack  I 
often  employ.  After  this  was  more  taciturn  and  confused,  and  the  defect 
of  articulation  more  marked.  Is  very  nervous,  tremulous,  stupid,  and 
unsteady,  and  displays  general  muscular  twitching,  best  marked  in  right 
side  of  face.  In  a  fortnight  after  admission  had  retention  of  urine,  and 
required  use  of  catheter.  Became  much  weaker ;  trembled  greatly ; 
limbs  jerked ;  face  twitched ;  only  rarely  could  be  got  to  utter  a  few 
words  spasmodically. 

Was  ordered  potass,  iodid.  gr.  x  and  potass,  bromid.  gr.  xxv  thrice 
daily.  After  this  tremors  less  marked ;  looked  very  exhausted ;  slept 
very  little ;  refused  food ;  became  more  obstinate  and  intractable ;  rarely 
spoke ;  had  an  expression  of  disgust  and  hopelessness ;  was  fed  with  dif- 
ficulty ;  catheter  used  twice  daily.  Refused  food ;  very  slow  and  stiff  in 
his  movements  at  times  ;  confusedly  excited.  On  the  twenty -fourth  day 
after  admission,  got  suddenly  worse ;  expression  haggard ;  face  pale.  In 
the  evening,  when  walking  to  his  bedroom,  he  suddenly  collapsed,  and 
expired  quietly. 

Autopsy — Head. — Skull-cap  dense;  dura  mater  thick;  pia  mater 
thick,  tough,  and  very  much  injected,  and  was  adherent  to  gray  matter 
over  posterior  part  of  orbital  surface  of  frontal  lobes.  Hemispheres  on 
section  extremely  injected,  especially  the  right.     Gray  matter  thin  here 


104  STATES    OF    MEXTAL    DEPRESSION. 

and  there.  In  left  optic  thalamus  two  distinct  softened  spots.  Basal 
ganglia,  pons,  medulla,  and  cord  very  hvpenemic.  Lining  membrane  of 
lateral  and  fourth  ventricles  thick  and  finely  granular. 

On  microscopic  examination  of  sections  of  the  brain,  there  were  found 
innumerable  microscopic  apoplexies  into  gray  and  white  substance,  great 
dilatation  of  the  arteries  and  capillaries,  and  a  universal  proliferation  of 
the  nuclei  of  the  neuroglia  and  connective  tissue  generally.  Along  the 
lines  of  the  smaller  vessels  there  appeared,  in  stained  sections,  vast  col- 
lections of  nuclei  clustering  round  the  vessels,  extending  far  into  the 
brain  tissue,  and,  of  course,  far  outside  the  perivasculai-  canals  (see  Plate 
VII.,  Fig.  4). 

Chest. — Aorta  atheromatous.  Lungs  congested  and  verv  oedematous. 
Other  organs  healthy. 

Suicidal  and  Homicidal  Melancholia. — The  question  of  the  pa- 
tient being  suicidal  should  never  in  any  case  of  melancholia  be  left  un- 
considered, and  the  risk  of  his  becoming  suicidal  should  never  in  any 
case  be  left  unprovided  for.  No  tendency  to  suicide  exists  at  all  in  many 
melancholies  from  beginning  to  end  of  their  disease,  but  it  does  exist  in 
some  form  or  other,  in  wish,  intention,  or  act  in  four  out  of  every  five  of 
all  the  cases,  and  we  can  never  tell  when  it  is  to  develop  in  any  patient. 
The  intention  and  the  act  mav  come  on  suddenlv.  bv  suggestion  fi-om 
without  or  within,  or  by  the  sight  of  opportunity  or  means  of  self-de- 
struction. When  a  man  takes  away  his  own  life,  or  even  when  a  serious 
attempt  is  made,  it  is  so  distressing  to  every  one  connected  with  the  pa- 
tient, so  hurtful  to  his  prospects,  and  so  damaging  to  the  reputation  and 
foresight  of  the  doctor  in  charge,  and  so  in  the  teeth  of  the  radical 
medical  principle  to  obviate  the  tendency  to  death,  that  no  pains  should 
be  spared  to  guard  against  its  occurrence.  While  it  prevails  so  com- 
monly in  all  forms  of  melancholia,  there  is  a  variety  of  this  disease 
which  is  specially  characterized  by  the  suicidal  intent  and  impulse,  and 
of  all  the  forms  of  mental  depression  this  is  one  of  the  most  striking  and 
most  important.  When  the  love  of  life,  that  primary  and  strongest  in- 
stinct, not  only  in  man,  but  in  all  the  animal  kingdom,  through  which 
continuous  acts  of  self-preservation  of  the  individual  life  of  every  li^-ing 
thing  take  place,  when  that  is  lost,  and  not  only  lost  but  reversed,  so 
that  a  man  craves  to  die  as  stronglv  as  he  ever  craved  to  live,  we  have 
then  the  greatest  change  in  the  instinctive  and  affective  faculties  of  man 
that  is  possible,  and  have  "reached  the  acme  of  all  states  of  mental  de- 
pression. Suicide  in  some  cases  is  a  desperate  impulse,  in  others  an  in- 
satiable hunger,  in  others  a  fixed  resolution  to  be  calmly  and  deliberately 
carried  out,  and  in  others  a  fi-antic  attempt  to  escape  imaginary  calamities 
or  tortures. 

The  determination  to  commit  suicide  is,  in  some  cases,  one  come  to  in 
the  calmest  and  most  reasoning  way.  A  patient  says — "  I'm  utterly 
miserable;  I  am  not  going  to  recover.  Why  should  I  live  in  torture?" 
and  so  determines  to  end  his  life.  Such  causes  are  nearest  in  character 
to  the  suicides  among  sane  persons  which  Morselli's  statistics^  show  are 
increasing  nearly  in  all  the  civilized  countries.      Next  to  this  mode  of 

'  Suicide,  Henry  Morselli. 


STATES    OF    MENTAL    DEPRESSION.  105 

arriving  at  the  suicidal  purpose,  in  my  experience,  come  the  attempts  to 
commit  suicide  from  the  motive,  illogical  as  it  seems,  to  escape  imaginary 
torture  or  persecution.  This,  too.  causes  one  of  the  most  common  mis- 
takes made  in  not  taking  precautions  against  it.  A  man  is  desperately 
afraid  he  is  going  to  be  hanged  for  some  imaginary  crime,  and  his  friends 
think  it  would  be  absurd  to  have  any  one  watched  against  taking  away 
his  own  life  who  seems  so  morbidly  fearftd  that  some  one  else  is  going  to 
do  it  for  him.  But  this  is  one  of  the  most  dangerous  class  of  cases. 
The  psychological  condition  of  such  a  person,  when  analyzed,  is  found  to 
be  this :  that  there  coexist  a  paralysis  of  the  life-love,  a  suicidal  longing, 
with  delusions  of  persecution  or  torture  side  by  side.  They  are  mental 
symptoms  of  the  same  brain  disorder.  A  very  suicidal  lady — B.  K. — 
in  this  state  wrote  a  friend:  "If  my  soul  and  body  could  both  die, 
this  would  be  my  salvation :  but  no.  this  will  not  be.  O  God !  how 
dreadftil  seems  my  case.  Sadness,  terror,  tortures  intolerable  will  be  my 
portion."  In  other  cases,  there  is  a  direct  delusion  or  hallucination 
leading  to  the  act  of  self-destruction.  The  patient  thinks  himself  too 
bad  to  live ;  that  he  pollutes  the  earth ;  is  a  source  of  misery  to  his  re- 
lations ;  that  he  must  sacrifice  himself  to  save  others ;  or  he  hears  voices 
— of  God,  of  the  devil,  of  friends  and  enemies,  dead  and  alive — saying 
to  him:  "•  Kill  yourself :"  "Cut  your  throat;'  or  there  is  a  longing  for 
death  simply,  so  intense  as  to  overpower  all  other  motives  and  considera- 
tions, without  any  delusion — a  death-love  that  acts  as  a  fascination.  Th«i 
there  are  cases  where  there  is  no  love  of  death  at  all.  but  rather  a  fear 
of  it.  Yet  an  ungovernable,  morbid  impulse  impels  the  patient  to 
commit  suicide  against  his  will,  and  contrary  to  any  resolution  he  is  able 
to  form.  Lastly,  there  is  the  epileptic  suicidal  impulse  while  the  patient 
is  in  a  state  of  false  consciousness,  with  no  memorv  of  the  act  afterwards 
at  all.  But  the  last  two  I  shall  treat  of  under  the  heading  of  impulsive 
insanity.  Naturally,  it  follows,  such  being  the  immediate  motives  to 
suicide,  the  act  is  carried  out  or  attempted  in  a  great  variety  of  ways. 
Sometimes  it  is  sudden,  the  desire  to  do  it  arising  in  a  moment,  without 
wammg :  m  other  cases,  it  is  led  up  to  by  the  clinical  history  of  the 
case  very  gradually ;  in  other  cases,  most  elaborate  preparations  have 
been  made  to  accomplish  it.  Twice  in  America — one,  I  think,  in  im  ta- 
tion  of  the  other — men  have  constructed  an  elaborate  apparatus,  taking 
months  to  make,  by  which  the  contriver  gave  himself  chloroform  first, 
and,  when  unconscious,  an  axe  was  let  loose,'  and  chopped  off  his  head. 
In  other  cases,  much  cunning  and  mendacity  are  used  to  throw  friends 
off  their  guard,  so  as  to  enable  patients  to  effect  their  purpose.  As  a 
general  rule,  the  more  it  is  talked  of  by  a  patient,  the  less  danger  of  its 
being  carried  out;  but  to  this  there  are  exceptions.  In  most  really 
serious  cases,  this  is  less  talked  of  by  the  patient  than  any  other  symptom 
of  melancholia.  The  most  absurd  precautions  are  sometimes  taken  in 
doing  the  act.  Very  often  patients  take  off  some  of  their  clothes  when 
going  to  cut  their  throats.  I  had  a  patient  once  who,  in  his  own 
house,  arranged  himself  most  carefiilly  over  the  seat  of  his  water-closet 
before  he  opened  a  vein  in  his  arm  with  a  penknife. 

\  arious  things  determine  the  real  amount  of  risk — the  intensity  of 
the  disease ;  the  amount  of  consciousness  and  volition  left ;  the  tempera- 


106  STATES    OF    MENTAL    DEPRESSION. 

ment  of  the  patient;  the  means  available;  the  suggestions  offered  in  the 
shape  of  opportunity;  that  is,  the  sight  of  knives,  ropes,  water,  open 
windows,  poison,  which,  in  certain  cases,  can  rouse  into  activity  a  till 
then  dormant  suicidal  desire;  and,  above  all,  the  natural  courage  and 
resolution  of  the  patient.  The  effect  of  the  last  element  is  overwhelm- 
ingly proved  by  the  fact  that  only  one  woman  commits  suicide  for  every 
three  or  four  men  in  all  countries,  the  suicidal  desire,  I  find,  being  more 
frequent  in  women  than  men.  There  are  some  hypochondriacal  and 
simple  melancholies  who  are  always  talking  of  suicide,  and  who  never 
go  further  than  talk  and  ostentatious  preparation.  I  have  referred  to 
the  hypochondriac  (A.  L.,  p.  69)  who  tried  to  hang  himself  by  pulling 
himself  up  a  flagstaff  with  one  end  of  the  rope  around  his  neck  and  the 
other  in  his  hand.  I  knew  a  patient  alarm  his  friends  by  drinking  a 
liniment  which  he  knew  to  contain  only  a  little  tinct.  saponis;  another 
who  went  and  bought  no  less  than  thirty  yards  of  rope,  hinting  his  fell 
purpose  to  the  shopman ;  another  who  was  always  tying  thread  and  gar- 
ters around  his  neck,  just  tight  enough  to  make  a  mark ;  and  many  who 
tried  to  end  their  lives  by  holding  their  breaths.  In  some  suicidal  cases, 
there  are  curious  automatic  suicidal  movements  quite  unconsciously  done. 
I  have  always  many  patients  who  would,  at  times,  put  their  hands  to 
their  throats,  and  compress  them  slightly.  Some  patients  regularly 
"work  at  their  throats"  in  that  way.  I  have  seen  continued  in  a  patient, 
as  an  automatic  muscular  habit,  the  mere  organic  memory  of  a  melan- 
cholic suicidal  state  which  had  then  passed  away,  the  patient  being  at 
the  time  cheerful  and  convalescent.  So  I  have  seen  patients  gently 
strike  their  heads  against  walls,  and  play  with  dinner  knives,  as  if  to  end 
themselves,  long  after  any  real  suicidal  desire  had  gone. 

Regarding  the  modes  of  committing  suicide,  there  are  eight  most 
common — drowning,  hanging,  starvation,  wounds,  fire-arms,  poisoning, 
precipitation  from  a  height,  and  asphyxia.  But  other  and  rarer  methods 
are  as  diversified  and  original  as  human  imagination  can  conceive. 

Some  things  seem  to  go  contrary  to  the  radical  instincts  of  human 
nature,  e.g.,  going  into  boiling  water,  or  swallowing  it,  or  putting  a  hot 
coal  into  the  mouth,  and  attempting  to  swallow  it.  But  I  have  seen  one 
example  of  each  of  all  these  modes  of  attempted  self-destruction.  "Each 
country,"  says  Morselli,  "has  certainly  its  particular  predilections."  He 
says,  too:  "  In  the  choice  of  the  means  of  death,  man  is  generally  guided 
by  two  motives — the  certainty  of  the  event  and  the  absence  or  shortness 
of  suffering."  I  disagree  entirely  with  this.  I  think  he  is  guided  by 
the  readiness  and  the  simplicity  of  the  means  at  hand ;  by  the  absence 
of  ideas  connected  with  them  repugnant  to  the  instincts  of  human  nature ; 
by  his  natural  temperament,  and  by  the  suicidal  traditions  of  his  country, 
or  race,  or  profession.  In  China  and  Japan  the  means  used  are  entirely 
different  from  those  in  Europe.  But  one  fact  is  of  great  practical  and 
prophylactic  importance.  The  same  patient  very  often  sticks  to  one 
means  of  suicide.  A  man  who  wants  to  cut  his  throat  or  drown  him- 
self will  frequently  pass  unattempted  innumerable  opportunities  of 
hanging.  Even  the  vanities,  follies,  and  eccentricities  of  human  nature 
come  out  strongly  in  the  modes  of  committing  suicide.  I  knew  a  man 
who  was  very  particular  about  his  linen,  and  could  not  bear  the  idea  of 


STATES    OF    MENTAL    DEPRESSION.  107 

cutting  his  throat,  because  it  would  soil  his  shirt-front,,  and  people  might 
say  he  had  not  had  on  a  clean  shirt  that  day,  while  he  was  most  anxious 
to  get  poison. 

Patients  frequently  starve,  or  attempt  to  starve  themselves,  in  order  to 
terminate  their  lives;  yet  food  is  by  no  means  always  refused  in  insanity 
with  that  direct  object.  It  is  refused  from  patients  having  delusions  about 
its  containing  poison;  as  to  their  not  being  able  to  pay  for  it;  as  to  their 
bowels  being  costive  or  obstructed;  as  to  their  having  no  stomach;  that 
they  would  burst  if  any  food  is  taken ;  they  hear  voices  telling  them  not 
to  take  it ;  or  there  is  simply  a  paralysis  of  the  appetite  for  food,  with  a  re- 
versal of  that  appetite  in  the  form  of  an  intense  dislike  to  it.  It  may  be 
convenient  here  to  refer  to  the  best  means  of  forcible  feeding.  If  per- 
suasion, a  little  starvation,  in  strong  cases,  and  fresh  air  and  exercise  do 
not  make  them  take  it,  patients  will  frequently  masticate  and  swallow  when 
it  is  put  into  their  mouths.  From  very  long  experience,  I  say  that  a  liquid 
custard  of  new  milk,  cream,  and  three  or  four  eggs,  flavored  with  a  dash 
of  nutmeg  or  sherry,  is  the  very  best  and  handiest  form  of  liquid  diet  at 
first,  and  for  a  time  at  least.  If  feeding  has  to  be  long  continued,  the 
best  way  is  to  have  a  big  mortar,  and  pound  into  a  liquid  form,  with 
beef  tea,  the  ordinary  diet.  Beef,  mutton,  fowl,  fish,  and  vegetables  of 
all  kinds  can  in  this  way  be  liquefied.  Always  add  one-fourth  of  a  pound 
of  sugar  to  each  meal,  and  feed  twice  or  thrice  a  day.  If  the  patient 
will  not  swallow,  the  simplest  and  most  available  of  all  apparatus  is 
about  six  inches  of  India-rubber  tubing,  from  a  baby's  feeding  bottle, 
that  can  be  got  at  any  chemist's,  and  a  small  funnel  of  any  sort.  With 
this  latter  inserted  into  one  end  of  the  tube,  and  the  other  end  well 
oiled,  and  passed  along  the  floor  of  the  nares  to  the  pharynx,  we  can 
pour  down  the  custard  in  tablespoonfuls,  and  the  patient  must  swallow 
it.  But  an  obstinate  patient  soon  gets  into  the  trick  of  expiring  just  as 
the  fluid  is  entering  the  pharynx,  and  so  blowing  it  out  of  his  mouth. 
There  are  now  made  French  red  rubber  elastic  tubes,  like  longer,  stouter 
catheters,  which  can  be  passed  down  into  the  oesophagus,  and  so  over- 
come this  difiiculty.  This  implies  no  forcible  opening  of  the  jaws,  and 
will  succeed  in  five-sixths  of  the  patients.  But  in  case  this  method 
fails,  we  must  use  the  French  rubber  tubes  of  large  size  passed  into  the 
stomach  by  the  mouth,  which  must  be  first  opened  by  a  suitable  instru- 
ment (to  be  got  from  all  good  instrument  makers).  This  mouth-opener 
should  always  be  tightly  wrapped  around  at  the  points  with  strong  tape 
to  protect  the  teeth.  Never  bring  the  steel  in  contact  with  the  teeth. 
If  there  is  very  great  difiiculty  in  opening  the  mouth,  two  openers,  one 
put  in  at  each  side  of  the  mouth,  and  both  screwed  up  at  once,  obviate 
all  difiiculty.  For  forcible  feeding  have  plenty  of  assistance.  Use  a 
large  stomach-pump,  or  a  funnel  at  the  end  of  the  tube  held  above  the 
patient's  head,  to  pass  the  liquid  nourishment  into  the  stomach.  Take 
care  the  patient  does  not  get  up  and  tickle  the  throat,  and  vomit  the 
food  after  the  meal.  With  good  tubes  and  instruments,  and  plenty  of 
assistance,  the  patient  being  placed  on  a  bed  or  sofa,  Avith  his  head  raised, 
he  can  be  fed  quickly  and  easily.  I  now  never  have  any  difiiculty.  I 
must  say,  however,  that  I  have  met  with  one  patient  where  I  could  not 


108  STATES    OF    MENTAL    DEPRESSION. 

pass  the  French  soft  rubber  tube,  and  where  I  had  to  use  the  old  stiffer 
gum-elastic  tube,  so  that  it  is  well  to  have  one  on  hand. 

My  experience  is  that  the  greatest  danger  of  suicide  is  near  the  com- 
mencement of  the  attack  of  melancholia.  The  impulse  is  then  strongest. 
Like  any  other  disease,  its  intensity  gets  spent  after  a  time.  So  with 
refusal  of  food.     It  is  orenerallv  most  troublesome  at  the  benrinning. 

As  showing  the  contradictory  feelings  in  a  mildly  suicidal  case,  this  is 
the  letter  of  one  (B.  K.):  "I  wish  you  would  come  to  see  me.  I  never 
sleep  at  all  now.  I  am  very  ill,  and  I  am  in  despair  about  my  soul's 
salvation.  I  wish  I  had  an  opportunity  for  suicide.  I  hope  to  see  you 
soon.  I  am  very  much  afraid  of  hell.  I  am  getting  worse,  and  I  see 
no  chance  of  getting  well.  I  sometimes  wonder  how  much  money  I  have 
lost.  I  am  afraid  of  losing  money  by  being  fined  for  blasphemous 
writings  or  whisperings  [which  he  indulged  in  often].  I  wish  I  was 
dead.  The  keepers  have  been  very  kind  to  me.  I  hope  to  live  with 
you  soon.  If  you  lived  in  Edinburgh  I  would  be  very  glad  to  see  you. 
I  am  afraid  of  dying  suddenly.  I  would  be  happier  with  you.  I  hope 
to  be  better  when  you  come.  Write  soon.  I  am  afraid  of  hell  very 
much.  Is  your  health  good  ?  Keep  your  money  safe  beyond  my  reach. 
Yours  affectionately." 

It  is  most  important  to  estimate  the  degree  of  intensity  of  the  suicidal 
feeling.  Is  it  quite  obviously  over-mastering  ?  Is  the  power  of  atten- 
tion greatly  impaired  ?  Are  the  natural  habits  or  propensities  changed  ? 
the  likings  and  antipathies  interfered  with  or  reversed  ?  Is  the  sense  of 
the  ludicrous  gone  ?  But  it  must  be  remembered  that  the  sense  of  the 
ludicrous  may  not  be  gone,  and  yet  a  serious  suicidal  intent  may  be 
present.  I  have  seen  outbursts  of  gayety  in  a  suicidal  melancholic.  Is 
the  capacity  for  ordinary  enjoyment  gone  ?  Are  the  delusions  wholly 
believed  in  or  only  partially  so  ?  Is  the  suicidal  feeling  much  spoken 
about  or  not  ? 

The  following  is  a  record  of  one  of  the  most  persistently  and  strongly 
suicidal  cases  I  ever  had  under  my  care : 

B.  L.,  a  professional  man,  aged  25,  of  melancholic  temperament ; 
nervous  and  reserved  but  kindly  disposition ;  temperate  and  industrious 
habits ;  had  been  a  hard  student.  A  cousin  of  his  mother  and  one  of  his 
great  maternal  great  aunts  were  insane.  Comes  of  a  professional  family. 
There  was  no  exciting  cause  for  his  illness.  Nine  months  ago  he  got 
dull  and  sleepless.  He  first  thought  he  did  not  do  his  professional  work 
well ;  then,  by  a  natural  transition,  as  his  disease  acquired  more  power, 
that  he  had  committed  some  crime  and  ought  to  die,  and  that  his  soul  was 
lost.  He  took  a  poisonous  dose  of  belladonna  with  suicidal  intent  before 
admission.  He  had  fallen  off  in  bodily  strength  and  flesh.  On  admission 
he  was  perfectly  coherent,  and  his  memory  good,  but  much  depressed, 
with  no  interest  in  anything,  and  with  the  delusions  above  mentioned. 
In  spite  of  treatment,  which  consisted  of  nutritious  food  and  tonics,  and 
attempts  to  get  him  employed  and  his  attention  aroused  to  healthy 
objects  of  interest,  he  got  steadily  worse.  His  pulse  was  weak,  his  tem- 
perature low,  his  muscles  flabby,  his  complexion  pale,  and  his  bowels 
costive.  He  walked  rapidly  about,  and  could  not  sit  down  long  or  settle 
himself.     He  said  he  was  troubled  much  with  seminal  emissions,  and 


STATES    OF    MENTAL    DEPRESSION.  109 

this  seemed  to  depress  him  further.  He  had  a  dislike  of  animal  food. 
He  made  innumerable  attempts  at  suicide  in  quiet,  reasoning,  deliberate 
ways.  He  put  his  fingers  down  his  throat ;  he  swallowed  berries  of  the 
Arbor  vitce  picked  in  the  grounds ;  he  swallowed  eighty-two  small  stones 
gathered  in  the  gravel  walks  (weighing  twenty-four  ounces),  and  passed 
them  without  doing  him  any  harm ;  he  tried  to  push  a  nail,  picked  up 
and  secreted  for  the  purpose,  into  his  heart ;  he  seized  a  bottle  of  whiskey 
one  day  and  drank  part  of  it.  Even  when  intoxicated  with  this  he  was 
miserable,  and  his  dreams,  he  said,  were  only  a  little  less  depressing  than 
his  waking  thoughts,  which  were  always  that  he  was  wronging  everyone 
by  allowing  himself  to  live,  and  that  he  ought  to  take  away  his  life  and 
so  end  his  misery  and  lessen  his  punishment  in  the  other  world.  He 
refused  his  food  for  a  time,  and  had  to  be  fed  with  the  stomach-pump. 
I  was  singularly  unfortunate  in  the  attendants  I  placed  in  charge  of  him, 
for  they  got  most  careless,  and  one  or  two  I  dismissed  on  his  account. 
He  was  so  quiet  and  reasonable  and  nice  a  man,  and  tried  so  successfully 
to  throw  them  oft'  their  guard,  and  his  attempts  were  so  carefully  planned 
that,  no  doubt,  a  man  unacquainted  with  disease  from  the  physician's 
point  of  view  was  most  apt  to  be  thrown  oft"  his  guard.  An  attendant 
will  be  most  alert  for  a  few  weeks,  but  when  it  comes  to  months,  and 
when  the  man  he  has  to  watch  seems  as  reasonable  as  he  is  himself,  and 
is  quiet,  it  is  almost  impossible  to  get  one  who  will  not  give  such  a  man  a 
chance  some  time.  The  whole  mental  energy  of  B.  L.  was  employed  all 
the  time  in  scheming  suicide.  And  when  such  a  man  is  a  doctor,  it  simply 
is  a  question  of  how  long  he  Avill  take  to  get  a  chance.  He  drank  some 
turpentine,  used  for  polishing,  once,  and  nfearly  died.  He  was  weak  and 
threatened  with  bed-sores,  and  his  attendant  got  a  solution  of  guttapercha 
in  chloroform  to  paint  over  his  skin.  B.  L.  seized  the  bottle  and  drank 
a  quantity  of  it.  We  had  to  use  artificial  respiration  by  Sylvester's 
method  and  the  interrupted  current  for  fourteen  and  one-half  hours, 
when,  to  our  surprise  aud  delight,  he  began  to  breathe,  and  told  us  to  "go 
to  hell."^  That  case  taught  me  many  lessons,  practical  and  medical.  I 
have  never  trusted  one  attendant  continuously  on  duty  in  such  a  case 
since.  I  have  never  believed  anyone  to  be  dead  since,  merely  because  he 
could  not  breathe  and  his  pulse  could  not  be  felt.  Six  months  after 
admission  poor  B.  L.  died  of  slow  exhaustion.  Food  would  not  nourish 
him ;  stimulants  would  not  rouse  him.  He  determined  to  die,  and 
accomplished  his  object  by  the  strength  of  his  volition. 

The  following  was  a  case  of  acute  suicidal  melancholia  coming  on 
suddenly,  caused  by  prolonged  afiiective  strain,  anxiety,  and  want  of 
sleep,  with  intense  suicidal  feeling,  and  many  attempts :  no  sleep ; 
exhaustion,  and  death  in  a  fortnight : 

B.  M.,  aet.  55,  a  man  of  a  melancholic  temperament,  nervous  diathesis, 
rather  over-sensitive  disposition,  great  intellectual  power,  and  good  edu- 
cation. For  months  he  had  had  too  little  sleep,  and  very  great  domestic 
anxiety.  This  did  not  seem  to  tell  on  him  till  a  sudden  outbreak  of 
intense  melancholia,  with  suicidal  feeling,  came  on  him  without  any  out- 

*  A  full  account  of  this  case  was  published  by  Dr.  J.  J.  Brown,  then  one  of  my 
assistants,  in  the  Edinburgh  Medical  Journal  for  November,  1874. 


110  STATES    OF    MENTAL    DEPRESSION. 

ward  warning.  But,  no  doubt,  he  was  a  man  with  immense  power 
of  inhibition,  who  had  the  capacity  to  work  his  brain  up  to  the  point  of 
complete  exhaustion,  and  also  conceal  from  others  any  evidence  that  he 
was  doing  so.  This  phenomenon  is  very  often  seen  in  women  nursing 
those  dear  to  them,  or  "keeping  up"  themselves  and  others  under  loss  or 
calamity.  They  look  cheery  up  to  the  last,  and  do  their  work,  but  they 
break  down  suddenly,  and  sometimes  incurably.  He  asked  one  morning 
that  his  razors  should  be  put  away,  and  within  an  hour  or  two  he  had 
entirely  lost  his  power  of  self-control,  gave  expression  to  the  intensest 
melancholic  delusions — that  he  was  too  wicked  to  live,  and  could  not 
live ;  that  he  was  lost,  ruined,  etc.  When  placed  in  charge  of  attendants, 
as  he  was  at  once,  he  made  many  and  desperate  attempts  at  suicide,  so 
that  he  could  not  be  left  for  a  moment.  He  could  not  be  roused  to 
attend  to  anything,  he  was  restless,  moaned,  and  never  expressed  any 
interest  again  in  his  Avife,  or  family,  or  concerns.  There  was  a  sudden 
paralysis  of  his  love  of  life,  of  wife,  and  of  children — of  his  interest  in 
anything  but  his  delusions.  His  tongue  was  furred  and  tremulous,  his 
facial  expression  that  of  despair,  his  pulse  feeble,  his  temperature  100°, 
his  appetite  gone,  his  bowels  costive,  and  his  skin  ill-smelling.  He  never 
seemed  to  rally,  and  died  Avithin  a  fortnight  of  the  acute  brain  disease, 
though  he  had  every  care  and  attention,  plenty  of  food  and  stimulants 
and  nursing.  The  cells  of  the  gray  matter  of  his  convolutions  were 
found  extensively  degenerated. 

Frequency  of  the  Suicidal  Impulse. — The  prevalence  of  the 
suicidal  tendency  in  melancholia  can  only  be  correctly  brought  out 
by  taking  large  numbers  of  cases.  I  have  taken  the  last  seven  hundred 
and  twenty-nine  cases  of  melancholia  under  treatment.  These  were  from 
all  classes  of  society,  and  this  is  a  valuable  point,  in  the  Morningside 
Asylum  statistics,  as  compared  with  those  in  an  asylum  for  paupers  only. 
The  disease  in  all  those  patients  was  decided  and  marked,  otherwise  the 
patients  would  not  have  been  sent  to  the  asylum.  All  the  very  mild 
cases  would  be  kept  at  home,  and  many  of  the  decided  cases  too  among 
the  richer  classes.  In  regard  to  melancholies  treated  at  home,  I  have  no 
means  of  ascertaining  the  prevalence  of  the  suicidal  feeling,  and  it  must 
be  kept  in  mind  that  many  of  my  patients  are  sent  to  the  asylum  on 
account  of  their  suicidal  tendencies  chiefly,  and,  but  for  these,  would 
have  been  at  home.  It  may  fairly  be  regarded,  then,  as  far  more  common 
among  asylum  melancholies  than  among  those  laboring  under  the  disease 
out  of  asylums.  Among  those  seven  hundred  and  twenty-nine  there 
were  two  hundred  and  eighty-three,  or  about  two-fifths  (thirty-nine  per 
cent.),  who  had  actually  attempted  to  commit  suicide.  In  many  cases,  no 
doubt,  the  attempts  could  scarcely  be  regarded  as  being  very  serious. 
In  addition  to  this  number  there  were  three  hundred  and  one  cases,  or 
two-fifths  more,  that  had  spoken  of  suicide,  or  given  some  indication  that 
it  had  been  in  their  minds.  That  makes  five  hundred  and  eighty-four  out 
of  seven  hundred  and  twenty -nine  melancholies,  or  four  out  of  five  of  the 
whole,  that  were  more  or  less  suicidal.  No  wonder,  therefore,  that  the  loss 
or  perversion  of  the  instinct  of  the  love  of  life  is  regarded  as  one  of  the 
chief  symptoms  of  melancholia.  I  am  quite  sure,  however,  from  what  I 
know  of  the  disease,  that  the  actual  risk  of  suicide   being   seriously 


STATES    OF    MENTAL    DEPEESSION .  Ill 

attempted  or  accomplished  is  much  less  than  those  figures  would  seem  to 
show.  The  really  typically  suicidal  variety  of  the  disease,  in  which  the 
desire  to  die  is  very  intense  and  is  the  chief  symptom  present,  the  cases 
of  which  would  certainly  put  an  end  to  their  lives  if  they  had  the  oppor- 
tunity, is  not  so  frequent.  As  near  as  I  can  estimate,  one  melancholic  in 
twenty  only  is  of  this  kind. 

There  is  one  peculiarity  about  the  suicidal  feeling  which  it  is  well 
to  keep  in  mind,  and  that  is  its  liability  to  return  suddenly  or  to  be 
called  up  by  the  sight  of  means  of  self-destruction.  I  had  a  patient  who 
was  all  right  so  long  as  he  did  not  see  a  knife.  That  set  up  the  demon  in 
him  at  once. 

The  homicidal  feeling  is  much  rarer  in  melancholia  than  the  suicidal. 
They  frequently  coexist ;  but  in  some  few  cases  the  homicidal  feeling 
exists  alone  without  the  other.  At  the  beginning  of  acute  alcoholism 
we  all  know  how  common  are  those  tragedies  that  shock  us  in  our  news- 
papers, men  killing  their  wives  and  children,  and  then  themselves.  We 
shall  also  see  that  in  puerperal  insanity  there  is  a  strong  tendency  in 
many  of  the  cases  towards  child-murder ;  but,  apart  from  those  two 
special  forms,  only  a  few  ordinary  melancholies  have  homicidal  feelings, 
of  which  the  following  case  is  an  example,  with  hallucinations  of  hearing 
voices  telling  her  how  to  commit  suicide,  and  a  homicidal  attempt : 

B.  P.,  aet.  30.  Widow ;  of  a  sanguine  temperament ;  frank  and 
cheerful  disposition ;  temperate  and  industrious  habits.  First  attack. 
Cause :  annoyance  at  some  legal  proceedings  three  days  ago.  Became 
depressed  and  very  restless,  sleepless,  and  her  appetite  disappeared.  She 
began  to  think  her  children  Avere  murdered,  and  that  people  were  going 
to  kill  her.  Whenever  you  see  such  delusions,  look  out  to  prevent  sui- 
cide. It  is  a  most  common  accompaniment.  She  had  hallucinations — 
hearing  voices  telling  her  to  commit  suicide,  which  she  attempted  by 
drowning.  Had  been  taken  to  the  police-office  on  emergency,  and  was 
at  once  sent  to  the  asylum.  On  admission  she  sufiered  from  intense 
mental  depression,  crying,  saying  she  had  been  drugged  at  the  police- 
office,  and  by  a  servant.  She  said  that  a  chimney-can  turning  with  the 
wind,  said  to  her:  "Drown  yourself,  prepare  yourself,  drown  yourself." 
She  was  excited  and  restless  in  manner,  and  jerky  in  her  muscles.  She 
could  answer  questions,  and  her  memory  was  not  gone.  Her  expression 
was  depressed,  suspicious,  and  alarmed ;  her  skin  muddy  and  spotted ; 
pupils  unequal ;  eyes  glistening ;  was  fat  and  muscular  ;  tongue  furred ; 
bowels  constipated ;  appetite  gone ;  refused  food  absolutely ;  was  men- 
struating. Temperature,  100.1°  ;  pulse,  108.  Was  restless  the  first 
night,  which  she  spent  in  a  dormitory  with  the  attendant,  who  twice 
during  the  night  sent  a  report  about  her  to  the  assistant  physician.  At 
5.30  A.M.  next  morning  she  m^de  a  most  severe  homicidal  attack  on  the 
attendant,  nearly  strangling  her.  Her  motive  for  this  was  not  expressed. 
It  might  have  been  a  pure  homicidal  impulse,  or  it  might  have  been,  and 
I  think  it  was,  from  the  delusion  that  the  attendant  was  going  to  murder 
her.  The  assistant  physician  after  this,  finding  that  it  was  to  be  a  con- 
tinuous struggle  with  the  attendants,  had  her  placed  in  a  bedroom  alone, 
with  the  shutters  locked  and  everything  made  secure,  as  he  thought,  with 
an  attendant  to  look  in  every  ten  minutes.     He  reported  this  to  me,  and 


112  STATES    OF    MENTAL    DEPRESSION. 

I  approved  of  the  mode  of  treatment.  She  refused  breakfast,  breaking 
her  dishes,  and  fighting  with  the  attendants.  She  was  seen  at  12.30  or 
12.35  by  the  attendant  lying  quietly  in  bed,  but  at  12.45  it  was  found  that 
she  had  hanged  herself  to  the  shutter  bar,  which  had  not  been  properly 
constructed,  with  a  piece  of  her  sheet,  her  feet  being  on  the  ground.  The 
efforts  at  artificial  respiration  were  unavailing. 

This  is  an  example  of  acute  suicidal  and  homicidal  melancholia,  the 
worst  of  all  cases  to  manage.  If  jou  keep  attendants  with  such  a  pa- 
tient, there  is  a  struggle  and  much  danger  to  both ;  if  you  place  him 
alone,  there  is  always  some  risk  of  suicide.  What  I  do  now  is  to  put  on 
such  a  patient  clothing  of  strong  untearable  linen,  to  give  for  bedding 
blankets  quilted  in  soft  untearable  canvas,  and  put  him  in  a  padded  room, 
with  an  attendant  outside  the  door.  It  will  be  seen,  from  the  tempera- 
ture and  whole  conditions  that  such  a  condition  has  many  of  the  charac- 
ters of  an  acute  disease.  Such  acute  symptoms  do  not  usually  last  long. 
If  we  can  tide  over  the  first  week  or  two,  we  expect  all  the  symptoms  to 
abate  after  that.  The  hallucinations  of  hearing  in  such  a  case  may  dis- 
appear, and  are  not  of  such  grave  import  in  prognosis  as  in  less  acute 
cases. 

The  homicidal  impulse  in  a  slighter  form  is  more  common.  I  have 
now  two  ladies  under  my  care — B.  Q.  and  B.  R. — who  kick,  and  punch, 
and  strike  their  attendants  and  fellow-patients,  declaring  they  cannot 
help  it.  One  of  them,  B.  Q.,  has  the  suicidal  impulse  too,  and  strikes 
her  head  and  breast.  She  cries  to  be  put  in  a  strait  waistcoat,  to  prevent 
this.  I  tried  this  once,  but  it  had  no  good  effect,  and  it  gave  her  no 
more  sense  of  security,  and  she  did  not  sleep  any  better.  In  the  other 
case,  B.  R.,  she  only  has  the  homicidal  feeling  in  the  morning.  In  the 
evening  she  is  quite  lively,  dancing  and  playing  on  the  piano,  and  smiling. 
The  homicidal  feeling  is  undoubtedly  the  human  instinct  of  slaughter 
and  destruction  in  a  morbid  fonn  possessed  by  all  men.  I  had  a  case  in 
which  it  seemed  to  result  from  an  excessive  production  of  motor  energy 
in  the  nerve  centres,  for  any  mode  of  expending  this  by  tearing  his 
clothes,  digging  in  the  garden,  fighting,  or  gymnastics  would  relieve  his 
homicidal  feeling  for  the  time.  I  take  it  that  such  a  case  is  very  analo- 
gous to  the  physiological  instinct  of  breaking  things  in  children.  Many 
of  the  excited  melancholies  tear  and  break  things,  and  fight,  and  attack 
those  near  them.  My  experience  is  that  not  more  than  one  in  fifty  mel- 
ancholies is  homicidal  in  any  degree,  and  not  more  than  one  in  a  hun- 
dred is  dangerously  so. 

It  must  always  be  remembered  that  a  large  number  of  patients  do  not 
conform  strictly  to  any  of  those  varieties  of  melancholia,  or  pass  from 
one  variety  into  another,  or  have  the  characters  of  two  or  even  three  of 
the  varieties.  The  following  is  such  a  case,  which  also  shows,  what 
always  exists  to  some  extent,  but  in  some  patients  more  markedly  than 
others,  viz.,  that  melancholia  is  a  brain  storm,  or  convolution  storm 
rather,  which  arises  gradually,  gathers  strength,  and  reaches  its  acme, 
after  which  it  slowly  loses  its  morbid  energy  and  passes  away.  During 
its  height  it  often  nearly  kills  the  patients  by  exhaustion,  as  in  this  case, 
and  would  kill  oftener  if  means  were  not  adopted  to  counteract  its  effects. 

B.  S.,  aet.  50.     Single.    No  occupation.    Fair  education.    Disposition 


STATES    OF    MENTAL    DEPRESSION.  113 

reserved.  Habits  correct  and  temperate.  One  previous  attack  of  mel- 
ancholia, duration  under  a  week,  treated  at  home.  No  hereditary  pre- 
disposition to  insanity  or  other  nervous  disease.  Predisposing  cause, 
previous  attack.  Exciting  cause:  change  of  life.  First  mental  symp- 
toms :  had  some  domestic  grief  which  greatly  upset  her,  became  unsettled 
and  depressed,  and  assigned  groundless  reasons  for  her  grief.  Has 
since  become  taciturn,  and  refused  food  for  two  days,  sleepless ;  not 
epileptic,  suicidal,  or  dangerous.  Duration  of  existing  attack  :  six  days. 
Great  depression,  constant  restlessness,  moaning  and  complaining, 
taciturnity  when  questioned,  refusal  of  food  and  medicine. 

On  admission:  great  depression,  will  not  answer  a  single  question, 
keeps  constantly  .moaning  and  crying  "Oh!  oh!"  looks  very  miserable, 
wanders  about  the  room  incessantly  wringing  her  hands.  Memory  and 
coherence  cannot  be  tested  ;  will  not  attend  to  questions.  Seems  to  have 
delusions  of  a  melancholic  character.  Is  a  thin,  middle-aged  lady. 
Muscularity  and  fatness  poor.  Appetite  absent.  Pulse  108,  regular  but 
small.     Temperature,  99.4°.     General  bodily  condition  very  weak. 

First  night  in  the  asylum  was  very  restless,  kept  up  a  constant  wail  of 
"Oh!  oh!"  Could  with  difficulty  be  got  to  swallow  a  little  fluid  food. 
"Typhoid"  expression;  very  sallow  look;  dark  ring  round  eyes;  dry, 
scaly  lips ;  temperature,  99.2°.  This  state  continued  and  increased  for 
about  a  fortnight  without  improvement.  Very  sleepless ;  constant 
piercing  wail,  very  distressing  to  other  patients.  Her  weakness  was 
extreme.  She  was  entirely  confined  to  bed  and  fed  every  half  hour 
with  liquid  food,  milk,  eggs,  beef-tea,  and  a  large  quantity  of  wine.  She 
then  began  to  improve  and  was  much  better  in  the  mornings,  and  got 
worse  in  the  afternoons.  Could  be  induced  to  speak  intelligently ; 
looked  less  depressed ;  took  a  fair  quantity  of  food ;  slept  better. 
Within  another  week  she  was  quite  convalescent,  gaining  in  flesh  and 
strength  very  rapidly.  At  the  same  time  desquamation  occurred  (this  I 
have  seen  in  several  patients  after  such  short  acute  attacks).  Still  a  want 
of  appetite.  Two  weeks  later  sent  out  on  pass.  Appetite  and  general 
health  improved.     Residence  in  asylum  four  weeks  and  ten  days. 

There  are  a  few  cases  of  depressed  feeling  with  exalted  intellectual 
condition.  Many  patients  exaggerate  their  former  happiness,  wealth, 
and  position  by  way  of  contrast  with  their  present  misery.  I  had  a  woman 
in  excited  melancholia,  groaning  all  the  time,  who  fancied  herself  a 
queen  ;  another  who  had  immense  wealth.  Some  of  the  cases  are  of  the 
nature  of  what  the  French  call  megalomania,  that  is,  the  expansive 
grandiose  exalted  state  of  mind  which,  as  a  mental  symptom,  is  best  seen 
in  general  paralysis,  coupled  with  ideas  of  persecution,  and  with  depressed 
feeling,  especially  at  times. 

The  Inception  of  Melancholia. — It  begins  in  nearly  all  patients  as 
simple  lowness  of  spirits,  and  lack  of  enjoyment  in  occupation  and 
amusement,  and  loss  of  interest  in  life.  This  may  be  premonitory  of 
the  disease  by  months  or  even  years,  and  happy  is  the  man  who  then 
takes  warning,  and  adopts  proper  treatment.  The  next  stage  is  that  of 
the  simple  melancholia  described  in  A.  B's.  case  (p.  57),  and  this  may  be 
of  long  or  short  duration,  and  may  pass  into  one  of  the  other  and  more 
serious  varieties.     As   a  general   rule   the  hypochondriacal   variety    is 


114  STATES    OF    MENTAL    DEPRESSION. 

longest  and  slowest  in  inception.  I  have  seen  the  delusional,  the  suicidal, 
and  the  excited  varieties  fully  developed  within  a  week  of  the  commence- 
ment of  the  first  symptoms,  but  this  is  rare.  I  have  seen  the  loss  of 
self-control  take  place  quite  suddenly,  a  man  being  calm  externally,  though 
dull,  in  the  early  morning,  and  by  ten  o'clock  a.m.  in  the  acutest  stage  of 
suicidal  and  excited  melancholia.  Many  patients  exercise  self-control 
strongly  for  a  time,  and  then  at  once  lose  it.  This,  however,  is  not 
common.  The  duration  of  the  disease  previous  to  the  admission  of  the 
case  into  an  asylum  is  a  good  test  of  the  rapidity  of  progress  of  the 
disease  in  its  full  stages  up  to  the  time  that  self-control  was  so  lost  as  to 
require  treatment  and  restraint  in  an  institution.  Of  three  hundred  and 
sixty-five  cases  in  which  information  on  this  point  was  obtained,  forty 
per  cent,  had  been  melancholic  for  periods  under  a  month  before  admis- 
sion ;  sixteen  per  cent,  for  periods  from  one  to  three  months ;  eight  per 
cent,  from  three  to  six ;  and  the  remaining  thirty-six  per  cent,  over  six 
months. 

The  delusions  in  many  cases  take  their  shape,  if  not  their  origin,  in 
painful  or  disagreeable  sensations  in  the  organs,  which  are  misinterpreted 
by  the  disordered  mind,  and  attributed  to  wrong  causes.  The  power  of 
morbid  attention  on  feelings  is  very  great  in  exaggerating  them,  and  even 
in  creating  them,  in  persons  of  the  nervous  diathesis.  In  some  cases  a 
paralysis  of  the  consciousness  of  natural  affection  is  the  first  symptom  of 
melancholia,  and  the  patients,  thinking  that  they  no  longer  love  their 
children,  get  depressed.  I  have  known  in  a  few  cases  a  craving  for 
stimulants  to  be  the  first  symptom.  I  knew  a  lady  in  whom  this  was  so 
each  time  she  became  melancholic,  which  she  did  at  each  pregnancy  and 
at  the  climacteric  period. 

The  ages  at  which  melancholia  comes  on  are  more  advanced,  on  the 
whole,  than  in  the  case  of  mania  (see  Plate  VI.).  Four  per  cent,  only 
come  under  twenty  ;  only  twenty  per  cent,  under  thirty.  The  largest 
proportion  of  cases  in  any  one  decennial  period  (twenty-five  per  cent.) 
occurred  between  forty  and  fifty,  while  there  was  twenty-three  per  cent, 
between  thirty  and  fifty ;  eighteen  per  cent,  between  fifty  and  sixty ;  and 
fourteen  per  cent,  over  sixty. 

Bodily  Symptoms  of  Melancholia. — The  premonitory  bodily 
symptoms  that  I  have  most  commonly  met  with  have  been  headaches, 
neuralgia,  confused  feelings  in  head,  want  of  appetite  or  indigestion,  cos- 
tiveness,  a  feeling  of  weariness  and  languor,  in  some  cases  restlessness,  in 
others  "biliousness,"  oxaluria,  and,  above  all,  the  two  symptoms  of 
sleeplessness  and  loss  of  body  weight.  When  the  mental  symptoms 
become  fairly  developed,  the  headache  and  neuralgia,  if  present,  usually 
disappear,  and  we  have,  instead,  a  brilliancy  of  the  eye,  a  tendency  for 
the  temperature  to  rise  a  little  at  night,  a  hebetude  or  some  other  change 
in  the  facial  expression,  a  furred  tongue,  which,  in  four  cases  out  of  five, 
is  neurotic,  resulting  from  the  deficient  innervation  of  the  stomach.  The 
want  of  appetite  often  becomes  a  repugnance  to  food,  the  sleeplessness 
becomes  complete,  the  constipation  great ;  in  about  fifteen  per  cent,  there 
is  a  temperature  over  99.5°.  Taking  three  hundred  and  sixty-five  cases 
at  random  I  found  constipation  in  fifty  per  cent. ;  sleeplessness  in  sixty 
per  cent. ;  want  of  appetite  in  sixty  per  cent. ;  pyrexia  in  fifteen  per 


STATES    OF    MENTAL    DEPRESSION.  115 

cent. ;  and  hallucinations  of  the  senses  in  twenty-five  per  cent. ;  epigastric 
pain  and  sinking  in  a  few;  headaches  and  sensations  of  binding,  of 
Aveight,  and  emptiness  in  the  head  in  a  few ;  heart  disease  in  a  few ; 
suppression  of  discharges  in  a  few ;  disappearance  of  skin  disease  in  a 
very  few.  Taking  the  general  bodily  health  and  condition,  I  found  I  had 
put  thirty-six  per  cent,  as  being  in  fair  general  bodily  condition  on 
admission;  fifty-seven  per  cent,  as  weak  and  in  bad  condition;  and  seven 
per  cent,  as  very  weak  and  exhausted.  The  heart's  action  is  markedly 
affected  in  all  the  acute  cases  and  in  many  of  the  others.  In  the  former 
the  condition  of  hyper-action  in  the  brain  seems  to  exercise  an  inhibitory 
influence  on  the  cardiac-motor  innervation,  causing  the  pulse  to  be  small, 
the  arterial  tone  to  be  Ioav,  and  the  capillary  circulation  to  be  very  weak 
indeed.  The  skin  is  in  the  acute  cases  greasy,  perspiring,  and  ill-smelling, 
In  most  patients,  however,  it  is  hard,  dry,  harsh-feeling,  and  non-perspir- 
ing. Sometimes  we  have  boils  (a  good  sign  often)  and  subacute  inflam- 
mations. 

Causatiox  of  Melancholia. — The  causes  of  melancholia  are  always 
popularly  supposed  to  be  some  calamity,  some  affliction,  some  remorse, 
or  religious  conviction,  that  has  produced  grief  and  sorrow.  As  physi- 
cians, we  know  how  utterly  far  this  is  from  the  truth.  If  I  were  asked 
my  opinion,  I  should  say  without  hesitation  that  more  melancholia  re- 
sults from  innate  brain  constitution  than  from  all  outside  calamities  and 
afflictions  of  mankind  put  together.  If  a  man  has  a  well-constitutioned 
brain,  he  will,  like  Job,  bear  calmly  all  the  afflictions  and  losses  that  the 
spirit  of  evil  can  invent  for  him.  It  is  impossible  to  make  such  a  man 
a  melancholic.  That  needs  some  innate  weakness,  some  predisposition, 
some  potentiality  of  disease,  some  trophic  or  dynamical  defect.  The 
friends  of  melancholic  patients  will  always  assign  a  cause  for  their  disease- 
To  them  the  occurrence  of  such  a  state  of  matters,  without  some  mani- 
fest cause,  seems  an  impossibility.  Who  ever  saw  a  newspaper  account 
of  a  suicide  without  either  a  cause  being  stated,  or  a  remark  implying 
that  there  must  have  been  some  outside  "cause?"  A  hereditary  predis- 
position to  mental  disease  was  admitted  in  about  thirty  per  cent,  of  the 
cases  of  melancholia  sent  to  the  Royal  Edinburgh  Asylum,  but  that  is 
very  far  from  representing  the  truth.  I  have  no  official  statistics  on  the 
point,  but  my  general  experience  agrees  with  that  of  others,  that  states 
of  depression  of  mind  are  hereditary  more  than  most  morbid  mental 
symptoms.  I  have  known  several  families  where,  for  four  generations, 
a  considerable  proportion  of  each  was  depressed  in  mind  more  or  less. 
Certainly  the  tendency  to  suicide  is  very  hereditary.  Next  to  heredity 
come  as  causes  disordered  bodily  functions,  and  after  them,  at  a  long  dist- 
ance, moral  and  mental  causes  of  depression.  Domestic  affliction  is  by 
far  the  most  frequent  of  the  last  in  the  female  sex,  and  business  anxie- 
ties in  the  male  sex. 

Prognosis. — Out  of  the  last  thousand  cases  admitted  to  the  Morning- 
side  Asylum,  fifty-four  per  cent,  have  recovered.  Within  the  seven 
years,  under  one  per  cent,  have  died  of  the  direct  exhaustion  fi-om  the 
disease  while  recent.  The  liability  to  relapse  after  recovery  is  best 
represented  by  the  number  of  previous  attacks,  which  had  existed  in 
about  one-third  of  all  the  cases.     It  must  be  remembered  that  those  sta- 


116  STATES    OF    MENTAL    DEPRESSION. 

tistics  refer  to  cases  so  ill  as  to  need  asylum  treatment.  I  have  no  doubt 
tliat  if  the  milder  eases  treated  at  home  Avere  included,  the  recovery  rate 
would  be  much  greater. 

The  things  that  enable  us  to  fonn  a  good  prognosis  are  youth ;  sudden 
onset;  an  obvious  cause  that  is  removable;  want  of  fixed  delusion; 
absence  of  hallucinations  of  hearing,  taste,  or  smell;  no  visceral  delu- 
sions; no  strongly  impulsive  or  epileptiform  symptoms;  no  picking  of  the 
skin,  or  pulling  out  the  hair,  or  such  trophic  symptoms;  no  long-con- 
tinued loss  of  body  weight  in  spite  of  treatment;  no  long-continued  in- 
attention to  the  calls  of  nature,  and  no  dirty  habits. 

But  be  guarded  in  giving  a  definite  pi'ogncsis  in  almost  every  case. 
The  greater  my  experience  becomes,  the  more  guarded  I  am.  Some  of 
the  most  favorable  looking  cases  will  deceive  you,  while  some  that  look 
most  hopeless  will  recover,  as  in  the  case  of  B.  S.  A.,  a  patient  of  mine, 
who  had  been  seven  years  melancholic,  suicidal,  and  sleepless,  and  who 
recovered  at  seventy-four,  and  is  now  quite  well,  and  doing  her  house- 
hold work. 

The  bad  signs  are  a  slow,  gradual  onset,  like  a  natural  evolution; 
fixed  delusions,  especially  visceral  and  organic  delusions ;  gradual  decay 
of  bodily  vigor;  persistent  loss  of  nutritive  energy  and  body  weight; 
convulsive  attacks  and  motor  affections  generally,  not  ideo-motor;  per- 
sistent hallucinations,  especially  of  hearing,  smell,  and  feeling;  picking 
the  skin  or  hair ;  persistent  refusal  of  food ;  an  unalterable  fixity  of  emo- 
tional depression  of  face,  or  persistence  of  muscular  expressions  of  mental 
pain  (wringing  hands,  groaning,  etc.);  persistent  suicidal  tendency  of 
much  intensity ;  arterial  degeneration ;  senile  degeneration  of  brain ;  no 
natural  fatigue  following  persistent  motor  efforts  in  walking,  standing, 
etc.;  a  mental  enfeeblement  like  dementia. 

Termination  of  Melancholia. — Of  the  cases  that  teiTuinated  in 
recovery,  fifty  per  cent,  recovered  within  three  months,  seventy-five  per 
cent,  under  six,  eighty-seven  per  cent,  under  twelve  months,  leaving  only 
thirteen  per  cent,  who  took  more  than  a  year  to  recover. 

In  most  cases,  recovery  is  gradual.  In  my  experience,  an  improve- 
ment in  the  bodily  condition  and  looks,  and  an  increase  in  the  body 
weight  and  appetite,  always  precede  the  mental  improvement.  The 
motor  restlessness  generally  passes  off  first.  The  patients  sit  down  and 
do  work  of  some  sort;  then  they  begin  to  eat  better;  then  the  delusions 
lose  their  intensity ;  then  the  sense  of  ill-being  is  less  oppressive.  There 
is  often  an  irritable  stage  as  improvement  sets  in.  I  have  one  patient 
whom  I  am  always  glad  to  hear  swearing:  I  know  then  that  he  is  going 
to  recover.  The  return  of  the  sense  of  well-being  is  the  last  to  come, 
and  along  with  it  tliat  surplus  stock  of  nervous  energy  that  constitutes 
health.  A  man  whose  nerve  capital  is  always  running  low  can  never  be 
said  to  be  in  really  good  safe  health.  When  I  see  a  patient  taking  on 
flesh  at  the  rate  of  three  or  four  pounds  a  week,  I  know  he  is  safe,  and 
will  make  a  good  recovery.  The  only  exceptions  to  this  ai'e  in  the 
long-continued  cases,  where  the  mental  functions  of  the  convolutions  are 
permanently  enfeebled  and  damaged,  and  in  whom,  as  the  depression 
passes  off,  Ave  have  a  fat  dementia  resulting.  This,  hoAvever,  is  much 
more  uncommon  in  melancholia  than  in  mania.      Some  patients — a  fcAV 


STATES    OF    MENTAL    DEPRESSION.  117 

— make  sudden  recoveries  in  a  few  days.  I  have  even  seen,  a  patient 
go  to  bed  very  melancholic,  and  get  up  quite  well,  saying — "  I  see  that 
all  these  fancies  were  mere  nonsense.  I  wonder  I  could  have  been  such 
a  fool  as  to  believe  them." 

A  few  of  the  cases  end  in  the  chronic  melancholia  I  have  described. 
They  are  nearly  all  middle-aged  or  old  people.  Many  of  the  cases 
pass  into  mania;  a  few  become  alternating  insanity;  and  a  few  pass 
into  dementia,  which,  in  that  case,  is  never  so  complete  and  absolute  a 
mental  enfeeblement  as  Avhen  it  follows  mania. 

Summary  of  Treatment  of  the  States  of  Mental  Depression. 
— If  the  brain  and  body  conditions  that  accompany,  if  they  do  not 
cause,  states  of  morbid  mental  depression  are  those  of  trophic  deficiency, 
as  we  have  seen  is  undoubtedly  the  case  in  most  instances,  then  it  neces- 
sarily follows  that  what  will  remedy  those  conditions  is  indicated,  and 
all  things  that  will  aggravate  them  must  be  avoided.  Even  in  the 
patients  where  there  is  no  demonstrable  lack  of  brain  or  body  nourish- 
ment, and  where  the  disease  is  more  of  a  purely  dynamical  brain  dis- 
turbance, and  a  disordered  energizing  of  the  convolutions  from  heredi- 
tary  instability,  yet  in  such  cases  there  is  lack  of  force  and  vitality  in 
the  brain.  We  make  the  conditions  of  life  of  a  melancholic,  therefore, 
as  physiological  and  favorable  as  we  can.  Every  therapeutic  agent  whose 
effect  is  tonic,  hunger-producing,  digestive,  vaso-motor,  and  generally 
nerve-stimulating  we  give.  Quinine  I  place  in  the  first  rank ;  iron,  the 
phosphates,  hypophosphates,  strychnine,  phosphorus,  etc.,  in  the  second; 
and  the  mineral  acids,  vegetable  bitters,  aloes,  arsenic,  gentle  laxatives, 
cholagogues,  diuretics,  and  diaphoretics  in  the  third.  Not  that  I  have 
not  seen  quinine  and  strychnine  over-stimulate,  and  have  to  be  stopped, 
and  iron  determine  blood  to  the  brain  in  a  way  to  do  harm,  but  those  ill 
effects  are  rare,  and  they  can  be  stopped  as  soon  as  observed.  The 
mineral  waters  of  our  own  country,  and  especially  of  Germany,  come 
under  the  same  category  as  those  tonics.  Many  a  commencing  melan- 
cholic have  I  seen  cured  most  pleasantly  by  a  short  stay  in'Schwalbach, 
Wiesbaden,  Carlsbad,  etc.  Of  course,  the  particular  kind  of  water 
must  be  determined  by  the  diathesis — the  purely  chalybeate  to  the 
purely  neurotic,  the  saline  to  the  gouty  and  rheumatic,  etc.  The  con- 
tinued current,  applied  not  too  strong,  and  passed  through  the  great 
nervous  centres,  is  greatly  trusted  by  some  Continental  physicians^  and 
I  have  seen  it  do  good  in  patients  with  the  element  of  stupor  present. 

Diet  and  regimen  are  of  the  highest  importance.  If  I  were  as  sure  of 
everything  else  in  therapeutics  as  this,  that  fi*esh  air  and  fattening  diet 
are  good  for  melancholic  people,  I  should  have  saved  myself  many  medical 
questionings.  Such  patients  cannot  have  too  much  fresh  air,  though  they 
mav  have  too  much  walking,  or  gymnastics,  or  muscular  fatigue.  It  is 
the  best  sleep-producer,  the  best  hunger-producer,  and  the  best  aid  to 
digestion  and  alimentation.  Without  it  all  the  rest  is  totally  useless  in 
most  cases.  Patients  cannot  fatten  too  soon  or  too  fast,  though  their 
stomach  and  bowels  may  be  overloaded,  and  their  livers  and  kidneys  may 
be  too  engorged.  Fatty  foods,  milk,  ham,  cod-liver  oil,  maltine,  eggs, 
farinaceous  diet,  easily  digested  animal  food,  such  as  fish,  fowl,  game,  etc., 
are  my  favorite  diet  for  melancholies.     Milk,  in  very  many  cases,  is  my 


118  STATES    OF    MENTAL    DEPRESSION. 

sheet-anchor.  I  have  given  as  much  as  sixteen  tumblers  a  day  with 
surprising  benefit.  The  nervous  diathesis  does  not  put  on  fat  naturally, 
therefore  we  must  combat  the  tendency  to  innutrition  by  scientific  dieting. 
Adipose  tissue  and  melancholia  I  look  on  as  antagonists ;  therefore  when 
we  want  to  conquer  the  latter  we  must  develop  the  former.  I  need  hardly 
say  that  the  capacity  of  digestion,  the  peculiarities  of  digestion,  and  the 
dietetic  likings,  and  even  the  idiosyncrasies  of  our  individual  melan- 
cholies, must  be  studied.  A  good  cook  is  an  aid  to  all  cases,  a  pleasure 
to  most,  and  a  necessity  to  some. 

Concerning  stimulants,  I  certainly  have  found  them  useful  in  many 
cases.  The  fattening  appetizing  ales  and  porters  work  wonders  on  some 
lean  anorexic  melancholies.  Good  wines  do  the  same.  Claret  or  Bur- 
gundy are  the  chief,  when  suitable  to  the  circumstances  of  the  patients, 
that  do  good.  The  stronger  stimulants  are  only  needed  in  the  exhausted 
cases,  except,  indeed,  when  whiskey  and  water  at  bedtime  is  a  good 
soporific.  Be  sure,  however,  that  it  is  not  the  hot  water  alone  that 
causes  the  sleep.  I  have  seen  a  tumbler  of  hot  water  taken  at  bedtime 
cause  sleep  as  quickly  as  when  mixed  with  a  glass  of  Avhiskey,  and  have 
a  better  effect  altogether.  When  a  patient  begins  fairly  to  gain  weight, 
all  alcoholic  stimulants  may  be  discontinued,  except  as  mere  luxuries. 
Change  of  air ;  mountain  or  sea  breezes  ;  change  of  scene ;  quiet  in  most 
cases ;  active  travel  and  bustle  in  a  few  of  the  less  serious  cases ;  long 
voyages,  if  we  are  quite  sure  that  the  disease  does  not  threaten  to  be 
acute — all  these  things  are  helpful.  We  enjoin  rest  from  exhausting  or 
irritating  work  ;  above  all,  escape  from  worry.  We  bring  a  different  set 
of  faculties  and  a  different  group  of  muscles  into  action  from  those  that 
have  been  employed  before.  Do  not  push  anything  that  is  too  great  a 
conscious  effort  for  the  patient  to  do.  Do  not  send  a  man  to  fish  if  fishing 
is  a  disagreeable  toil,  or  make  him  go  into  "cheerful  society"  when  this 
is  a  real  torture  to  him.  Pleasant  society  with  no  bustle,  beautiful 
scenery,  music,  and  sunshine,  are  all  healing  to  melancholy.  In  most 
cases  some  occupation  that  is  a  pleasure  has  to  be  encouraged,  and  does 
much  good.  Fishing,  easy  mountaineering,  shooting,  boating,  out-door 
games,  are  most  suitable  for  certain  cases.  We  try  and  make  the  im- 
pressions received  by  the  senses  agreeable,  and,  therefore,  harmonious 
with  the  well-being  of  the  organism.  We  try  and  substitute  pleasurable 
feelings  for  painful  ones  by  every  means  known  to  us.  SIoav  travel,  with 
a  cheery,  sensible  companion,  Avho  is,  of  course,  twice  as  valuable  if  he  is 
a  doctor,  saves  many  a  man  from  an  asylum.  In  most  cases  we  remove 
a  man  temporarily  from  his  wife  and  fiimily,  for  paralyzed  or  perverted 
affection  to  a  melancholic  is  itself  a  painful  thing  and  a  source  of  de- 
pression. But  there  are  marked  exceptions  to  this  rule — cases  where  a 
man's  wife  is  the  best  nurse,  his  children  his  best  companions.  In  bad 
cases  a  cheerful  trained  attendant  and  a  young  doctor  make  a  capital 
team  for  the  melancholic  who  needs  attention,  company,  and  medical 
supervision.  We  try  to  remove  the  patient  from  surroundings  that  are 
depressing  to  those  that  will  rouse  pleasant  thoughts,  and  to  take  him 
from  the  place  where  his  malady  arose.  Everything  and  every  person 
there  may  suggest  pain  to  him.  But  he  must  not  always  have  his  own 
way.     Quite  the  contrary.     In  most  instances  another  will  must  over- 


STATES    OF    MENTAL    DEPRESSION.  119 

come  his  own,  and  be  substituted  for  it.  This  is  a  reason  why  mothers, 
wives,  and  sister  do  harm,  because  they  let  the  patient  have  too  much  of 
his  own  way.  It  is  certainly  well  if  those  about  him  have  physiologically 
a  surplus  stock  of  animal  spirits  to  infuse  into  him.  Much  tact  is  needed 
in  personal  intercourse  with  melancholies,  as,  indeed,  with  all  the  insane. 
Never  argue  with  them  on  any  account,  or  contradict  their  delusions. 
Do  not  agree  with  them,  but  change  the  subject.  Discourage  introspec- 
tion, encourage  observation  of,  and  talk  about  things  without  them. 
Every  neurotic  man  should  have  an  out-door  hobby.  That  would  save 
many  of  them  from  melancholia. 

Guard  against  suicide,  and  make  the  friends  and  attendants  feel  that 
there  is  a  real  risk  of  its  being  committed.  They  get  into  the  state  of 
mind  of  raihvay  porters,  avIio  are  so  accustomed  to  risks  that  they  do  not 
guard  against  them.  I  have  seen  suicidal  melancholies  by  the  dozen, 
about  whom  I  had  given  warnings  as  strong  as  I  could  make  them,  that 
every  article  by  which  suicide  might  be  effected  should  be  removed,  and 
yet  found  knives  in  their  pockets,  and  razors  in  their  dressing-cases. 
The  bad  cases  should  never  be  left  alone.  I  once  had  a  suicidal  patient 
under  the  charge  of  an  attendant,  Avho  was  said  to  be  experienced,  and  I 
found  my  patient  in  a  top-stoi'y  room  alone,  with  a  loaded  revolver  in  his 
pocket,  and  a  razor  case  in  his  room,  and  yet  his  mother  and  his  attendant 
did  not  seem  to  see  how  great  the  risk  had  been. 

Many  melancholies  are  intensely  selfish,  think  of  nobody  but  them- 
selves, bore  their  friends  with  recitals  of  their  own  feelings,  and  crave 
sympathy  with  a  morbid  intensity.  Too  much  expressed  sympathy  in 
most  cases  feeds  the  disease.  To  distract  the  attention  from  morbid 
thoughts  and  feelings  by  any  means  should  be  the  one  great  aim  in  per- 
sonal intercourse.  Strangers  often  do  better  with  melancholies  than 
friends.  Many  of  them  take  most  strong  and  unfounded  morbid  dislikes. 
They  exercise  more  self-control  before  strangers,  and  the  strengthening 
of  the  power  of  self-control  is  half  the  cure.  That  is  why  removal  to  an 
asylum  is  sometimes  followed  by  immense  benefit.  A  patient  who  at 
home  has  been  groaning,  noisy,  idle,  and  unmanageable,  finds  himself 
among  strangers  subjected  to  rules  and  discipline  and  ordinary  living, 
and  has  objects  of  fresh  interest  presented  to  him,  and  he  becomes  a 
different  man  at  once.  I  asked  a  man  Avho  had  been  very  ill  and  un- 
manageable at  home,  and  who  seemed  to  come  round  in  a  few  days  in 
the  asylum,  what  had  cured  him  ?  His  reply  was,  "  I  found  myself 
among  a  lot  of  people  who  did  not  care  a  farthing  whether  I  was  miser- 
able or  not,  which  made  me  angry,  and  I  got  well."  Being  by  far  the 
most  conscious  form  of  insanity,  it  would  seem  the  hardest  on  the  patients 
to  send  them  to  an  asylum,  but  in  reality  removal  to  an  asylum  does 
more  good  to  certain  melancholies  than  to  any  other  class  of  the  insane. 
What  is  good  is  not  always  pleasant  in  moral  as  well  as  in  medical  treat- 
ment. There  is  no  use  dunning  a  patient  to  "rouse  yourself,"  to  "throw- 
off  your  dulness,"  to  "  drop  these  fancies,"  for  in  many  cases  it  would 
just  be  as  wise  to  tell  a  hemiplegic  to  "  move  that  leg." 

Good  nursing  in  the  weak  cases,  just  as  you  would  nurse  a  fever  patient, 
is  of  the  last  importance.  A  nurse  that  will  insist  and  persist,  till  the 
insane  opposition  and  the  repugnance  to  food  are  overcome,  is  what  we 


120  STATES    OF    MENTAL    DEPRESSION. 

want.  It  is  most  easy  to  let  a  melancholic  slowly  starve  himself,  while 
he  yet  takes  some  food  at  every  meal. 

As  regards  the  sending  a  patient  to  an  asylum,  and  when  to  do  it,  no 
rules  can  be  laid  down.  Among  the  poor  it  must  be  done  in  nearly 
every  case,  and  soon,  though  now-a-days  a  working  man  can  get  a  com- 
plete change  of  air  and  scenery  for  a  shilling.  Among  the  very  rich, 
fcAv  melancholies  are  sent  to  asylums  till  their  relations  are  tired  out  with 
them,  or  they  become  very  suicidal.  No  doubt  the  risks  of  suicide  are 
much  less  in  an  asylum.  There  are  discipline,  order,  a  life  under  medical 
rule,  suitable  work,  much  amusement,  and  the  means  of  carrying  out 
what  is  good  for  the  patient.  When  from  any  cause  you  cannot  get  the 
treatment  carried  out  that  you  know  is  necessary  for  the  patient,  then  an 
asylum  is  needful.  When  the  symptoms  persist  too  long  without  showing 
signs  of  yielding,  when  the  risk  of  suicide  is  very  great,  when  the  j^atient 
has  foolish  friends  who  will  not  carry  out  any  rational  plan  of  treatment, 
or  when  he  gets  too  much  sympathy,  or  none  at  all — in  all  these  cases 
an  asylum  is  indicated.  Many  patients  who  resist  all  right  treatment  at 
home  will  submit  to  it  at  once  in  an  asylum. 

Baths  are  most  useful,  especially  Turkish  baths.  I  have  seen  many 
chronic  incurable  melancholies  much  improved  by  a  course  of  Turkish 
baths.  The  wet  pack  is  often  useful.  One  great  difficulty  one  has  in 
treating  a  case  of  melancholia  is  whether  to  give  narcotics  and  sedatives, 
when  to  give  them,  what  to  give,  and  when  to  stop  them.  Opium  I 
utterly  disbelieve  in.  I  performed  a  series  of  elaborate  experiments  with 
it  in  melancholia,^  and  it  always  caused  a  loss  of  appetite,  and  loss  of 
weight  in  every  case,  and  Dr.  Mickle  has  confirmed  these  results.^  I 
have  only  seen  one  melancholic  in  which  I  was  sure  opium  did  good. 
Chloral  is  most  useful  as  a  temporary  expedient  to  get  sleep.  I  now 
always  give  small  doses — never  more  than  twenty-five  grains,  generally 
keeping  to  fifteen,  combined  with  from  twenty  to  fifty  grains  of  the 
bromide  of  potassium  or  sodium  or  ammonium.  But  I  now  seldom  give 
chloral  long.  I  am  satisfied  that  one  effect  of  its  prolonged  use  is  to 
reduce  the  tone  of  the  nervous  system,  and  to  lessen  the  power  of  en- 
during pain,  mental  or  bodily.  The  bromides,  too,  when  long  given 
are  depressing.  Tincture  of  henbane,  in  doses  from  one  di-achm  to  four, 
is  very  useful  as  a  temporary  expedient  in  the  very  agitated  cases,  and 
so  is  conium  ;  but,  of  all  the  narcotics,  I  have  found  a  mixture  of  tinct. 
cannabis  indica  (from  x.  min.)  and  bromide  of  potassium  (from  xx.  grs.) 
do  the  most  good  and  the  least  harm  to  the  appetite  for  food.  We  have 
not  yet  discovered  the  narcotic  that  gives  brain-quiet,  combined  with  in- 
creased appetite  and  body  weight.  Tinct.  lupuli  I  have  found  of  much 
service  in  some  mild  cases,  and  it  did  no  harm  whatever. 

I  have  seen  many  cases  cured  by  a  crop  of  boils,  a  carbuncle,  or  an 
attack  of  erysipelas,  and  in  one  case  by  an  attack  of  dysenteric  diarrhoea. 
I  think  we  shall  some  day  be  able  to  inoculate  a  septic  poison,  and  get  a 
safe  manageable  counter-irritant  and  fever,  and  so  get  the  "  alterative  " 

^  "  Fotliergillian  Prize  Essay  for  1870,"  Brit,  and  Foreign   Med.-Chir.  Review, 
October,  1870,  and  January,  1871. 
^  Practitioner,  June,  1881. 


STATES    OF    MENTAL    DEPEESSION.  121 

effect  of  such  things,  and  the  reaction  and  the  stimulus  to  nutrition  which 
follow  febrile  attacks. 

Prophylaxis  in  Melancholia. — I  think  our  profession  could  di- 
minish the  amount  of  melancholia  if  they  were  consulted  sooner  and 
more  as  to  the  prophylaxis  in  patients  who  have  had,  are  threatened 
with,  or  who  are  predisposed  to,  states  of  mental  depression.  Especially 
is  the  preventive  aspect  most  important  in  the  dieting,  regimen,  educa- 
tion, and  work  of  the  children  of  this  class.  If  Ave  could  make  all  these 
things  counteractive  of  the  temperament  and  heredity,  instead  of  being 
developmental  of  them,  we  could  do  much  good,  and  prevent  an  enormous 
amount  of  unhappiness  in  the  world.  It  is  surprising  how  soon  such 
children  show  their  brain  instability.  A  "too  sensitive"  child  should 
always  be  looked  after.  Children  of  this  class  take  "crying  fits"  and 
miserable  periods  on  slight  or  no  provocation.  We  do  not  call  these 
things  melancholia,  but  depend  upon  it  they  often  have  a  close  kinship 
to  it.  Such  children  should  be  kept  fat  from  the  beginning  ;  they  should 
get  little  flesh  diet  and  much  milk  till  after  puberty.  Their  brains  should 
not  be  forced  in  any  way.  They  should  be  much  in  the  fresh  air.  They 
should  not  read  much  imaginative  literature  too  soon.  They  should  be 
brought  up  teetotalers  and  non-smokers.  They  should  sleep  much.  Public 
school  life  is  often  most  detrimental  to  them.  If  they  are  bullied,  they 
suffer  frightfully.  (Read  poor  Cowper  and  Lamb's  lives.)  If  they  are 
taught  masturbation,  it  takes  a  frightful  hold  of  them,  and  it  is  they  who 
are  ruined  by  it  in  body,  mind,  and  morals.  The  modern  system  of 
cramming  and  competitive  examinations  are  the  most  potent  devices  of 
the  evil  one  yet  found  out  for  the  destruction  of  their  chances  of  happi- 
ness in  life.  Such  children  are  often  over-sensitive,  over-imaginative, 
and  too  fearful  to  be  physiologically  truthful ;  tend  under  fostering  to  be 
unhealthily  religious,  precociously  intellectual,  and  hyperaesthetically  con- 
scientious. Now,  a  Avise  physician  will  fight  against  the  average  school- 
master in  all  these  things.  Such  children  should  be  taught  to  systematize 
their  time  and  their  lives,  to  develop  their  fat  and  muscle,  and  to  lead 
calm  lives  of  regular,  orderly  occupation. 

As  regards  the  prophylaxis  in  those  who  have  already  suffered  from 
melancholia,  at  the  risk  of  being  thought  to  ride  a  hobby,  I  tell  such 
persons,  one  and  all,  to  keep  fat.  Let  them  take  precautions  in  time. 
The  falling  off  of  a  foAV  pounds  in  weight  may  be  to  them  the  first  real 
symptom  of  the  disease  returning,  even  though  they  feel  at  the  time  as 
well  and  hearty  as  possible.  It  is  at  this  stage  that  change  and  rest  do 
real  good.  I  always  advise  my  recovered  melancholic  patients  to  weigh 
themselves  every  month,  and  keep  a  record  of  their  weight,  to  lead  a 
regular  life,  and  to  prastise  system  and  order  in  their  work.  Reducing 
their  ordinary  lives  to  a  routine  is  the  safest  thing  for  them  if  they  can 
do  it.  Like  leanness,  Avant  of  system  and  method  go  with  a  tendency  to 
melancholia,  in  my  experience.  They  should  not  work,  or  think,  or  feel 
in  big  spurts.  And  as  the  crises  of  life — the  climacteric,  pregnancy, 
child-birth,  and  senility — approach,  let  special  care  be  taken  by  them. 
Do  not  let  them  get  to  depend  on  soporifics  for  sleep.  Nothing  is  more 
dangerous.     An  hour's  natural  sleep — "tired  nature's  sweet  restorer" — 


122  STATES    OF    MENTAL    DEPRESSION. 

is  worth  eight  hours'  drug-sleep.  A  country  life,  with  much  fresh  air,  is 
no  doubt  the  best,  if  it  is  possible.  Regular  changes  of  scene,  "breaks" 
in  occupation,  and  long  holidays,  are,  of  course,  most  desirable  for  some 
people.  Though  travel  and  change  are  very  often  harmful  to  actual 
melancholic  patients,  yet,  to  many  persons  who  merely  have  the  tempera- 
ment and  the  tendency,  they  are  most  effective  in  warding  off  attacks.  I 
know  several  people  who  in  that  way  keep  well  and  moderately  happy. 
The  great  thing  to  be  avoided  is  too  fatiguing  travel — seeing  too  much  in 
too  short  a  time. 


LECTURE    IV. 

STATES  OF  MEXTAL  EXALTATION— MAiSTIA  {PSYCHLAMPSIA). 

Like  conditions  of  mental  depression,  states  of  mental  exaltation,  up 
to  a  certain  degree,  may  be  normal  and  physiological.  This  is  especially 
apt  to  be  the  case  in  persons  combining  the  sanguine  temperament  and 
the  nervous  diathesis.  Every  one  has  met  with  the  sort  of  person  who 
is  easily  elated,  has  little  power  of  controlling  the  outward  manifestations 
of  exalted  emotion,  is  quite  carried  away  by  joyous  news  or  pleasurable 
feeling,  so  that  he  talks  loud  and  fast,  cannot  sleep,  cannot  rest,  acts  in 
strange,  excited  ways,  and  perhaps  dances  and  sings — all  without  a  cause 
that  appears  sufficient  to  produce  these  effects.  Such  conduct  may  be 
perfectly  natural  and  physiological  in  any  man,  if  the  cause  be  sufficient; 
but,  in  the  Teutonic  races,  at  all  events,  such  causes  do  not  occur  very 
often  in  the  adult  lifetime  of  an  ordinary  man.  If  such  mental  exalta- 
tion does  occur  in  any  one  on  quite  insufficient  cause,  or  if  it  continues  to 
manifest  itself  long  after  the  cause  has  operated,  we  say  that  such  a 
person  is  of  an  "excitable  temperament."  Many  bodily  diseases  in 
persons  of  tliis  constitution  are  apt  to  be  accompanied,  and  are  often 
much  complicated,  by  such  brain  excitement. 

Mental  exaltation  is  perfectly  natural  in  childhood.  It  is,  in  fact,  the 
physiological  state  of  brain  at  that  period.  Hence,  whenever  the  tem- 
perature of  the  brain  rises  fi'om  febrile  disorders  in  children,  we  are  apt 
to  have  delirious  mental  exaltation.  But  if  a  grown  man  exhibited  the 
same  symptoms  of  mental  exaltation  as  a  child,  it  would  be  accounted 
morbid,  and  he  would  be  reckoned  insane.  In  children  of  the  constitu- 
tion I  have  referred  to,  this  is  apt  to  become  a  most  serious  complication. 
While  a  high  temperature  is  apt  to  cause  violent  delirium  in  such 
children,  it  is  in  them,  too,  that  reflex  peripheral  irritations,  such  as 
teething,  worms,  undigested  or  indigestible  food  in  the  stomach,  cause 
convulsions.  In  adults  of  this  constitution,  a  febrile  catarrh,  a  mild 
attack  of  rheumatism,  or  gout,  or  inflammation  may  be  most  serious 
matters,  from  the  sleeplessness,  nervous  excitement,  intensity  of  the  pain, 
or  the  delirium  present.  All  febrile  affections  act  as  a  match  to  gun- 
powder in  such  a  brain.  The  exaltation  and  delirium  are  usually  con- 
temporaneous with  the  beginning  and  acme  of  febrile  attacks,  while 
depression  of  mind  follows  the  disease.  I  consider  that  the  bodily 
temperature  at  which  delirium  begins  in  a  child  is  a  good  index  of  its 
brain  constitution  and  temperament.  I  have  known  a  very  nervous 
child  always  delirious  if  its  temperature  rose  to  100°,  while  in  most 
children  this  does  not  take  place  till  it  is  102°  or  over.  Then,  apart 
from  increased  temperature,  such  children  are  subject  to  gusts  of  unrea- 
soning elevation,  during  which  they  are  quite  beside  themselves,  rushing 


124  STATES    OF    MENTAL    EXALTATION. 

about  wildly,  shouting,  fighting,  and  breaking  things,  not  really  knowing 
what  they  are  about,  this  coming  at  intervals  like  the  "attacks"  of  a 
disease.  Most  sorts  of  blood-poisons,  many  drugs,  such  as  opium, 
henbane,  Indian  hemp,  and  alcohol,  as  well  as  an  increase  of  body  tem- 
perature, readily  cause  maniacal  exaltation  in  the  brains  of  which  I  am 
speaking ;  and  I  have  seen  such  usually  temporary  exaltation  not  pass  off, 
but  become  a  prolonged  attack  of  mania  in  several  patients — one  after  a 
dose  of  cannabis  indica,  another  after  opium,  and  more  than  one  after 
alcohol.     All  were,  of  course,  strongly  predisposed  to  insanity  by  heredity. 

There  is  much  less  difficulty  in  draAving  the  line  in  most  cases  between 
sane,  or  even  between  merely  delirious  exaltation,  and  pathological  insane 
exaltation,  than  between  the  conditions  of  sane  and  insane  depression  of 
mind,  though  many  individual  cases  of  difficulty  are  met  with.  The 
reasoning  power — that  of  judging  rightly,  and  comparing — is  affected 
sooner  and  more  decidedly  in  mania,  and  the  loss  of  control  in  action, 
conduct,  and  muscular  movements  is  also  sooner  seen.  That  stage  of 
loss  of  memory  and  consciousness  where  the  personality  is  lost,  and  the 
former  mental  life  and  experiences  have  disappeared,  where  in  fact 
the  metaphysical  ego  has  fled,  and  a  false  consciousness — an  unreal  ego — 
has  taken  its  place,  is  far  sooner  reached  in  mania  than  in  melancholia. 

The  name  Mania  is  apt  to  be  used  both  professionally  and  popularly  in 
a  loose  way  as  synonymous  with  insanity,  or  even  to  indicate  a  mental 
craze  or  eccentricity  that  falls  short  of  that.  This  is  a  very  great  pity, 
for  we  shall  never  in  mental  diseases  make  satisfactory  progress  till  we 
get  an  accurate  scientific  nomenclature.  The  loose  way  in  which  the 
present  terms  are  used  is  certainly  an  excuse  for  those  who,  like  the  late 
Professor  Laycock,  coined  a  new  medico-psychological  terminology 
altogether,  to  express  morbid  mental  conditions.  Nothing  is  more 
common  than  to  see  in  medical  papers  "suicidal  mania,"  when  "suicidal 
melancholia"  was  meant.  It  is  necessary,  therefore,  to  define  the  terai. 
Mania  might  be  defined  as  morbid  mental  exaltation  or  delirium,  usually 
accompanied  by  insane  delusions,  always  by  a  complete  change  in  the 
habits  and  modes  of  life,  mental  and  bodily,  by  a  loss  of  the  power  of 
self-control,  sometimes  by  unconsciousness,  and  loss  of  memory  of  past 
events,  and  almost  always  by  outward  muscular  excitement,  all  those 
symptoms  showing  a  diseased  activity  of  the  brain  convolutions.  We 
think  of  melancholia  chiefly  from  the  patient's  subjective  point  of  view, 
taking  his  affective  change  and  his  conscious  mental  pain  chiefly  into  con- 
sideration, while  we  think  of  mania  more  from  our  own  objective  point  of 
view,  and  picture  the  patient's  talkativeness,  his  restlessness,  and  his  mani- 
fest changes  of  personality  and  habits :  just  as  in  neuralgia  we  think 
of  the  patient's  sensations,  and  in  tetanus  of  the  convulsions  which  we 
see  for  ourselves.  The  definition  of  mental  exaltation,  too,  must  not  be 
taken  as  if  it  were  the  mere  opposite  of  depression  or  of  mental  pain. 
Mental  exaltation  in  its  medico-psychological  sense  is  not  consciously  felt 
mental  pleasure.  It  may  be  that,  but  as,  in  most  cases  of  acute  mania  at 
all  events,  we  have  the  unconsciousness  of  former  mental  acts  as  well  as 
of  present  circumstances,  this  definition  could  not  properly  apply  to  these 
cases.  I  would,  therefore,  define  morbid  mental  exaltation  to  be  a  mor- 
bidly increased  production  of  mental  acts  by  the  brain  with  or  without  an 


STATES    OF    MENTAL    EXALTATION.  125 

increased  sense  of  well-being  or  pleasure,  but  distinctly  without  a  conscious 
sense  of  ill-being  or  mental  pain.  The  word  excitement  used  medico- 
psychologically  refers  always  to  outward  visible  muscular  acts,  such  as 
restlessness,  muscular  resistance,  acts  of  violence,  shouting,  facial  expres- 
sions, contortion,  or  movements  or  expressions  of  the  eyes,  or  to  an 
intense  desire  towards  such  acts  restrained  by  a  strong  exercise  of  self- 
control. 

Most  melancholic  patients  can  tell  us  how  they  feel.  They  know  there 
is  something  wrong  with  them,  exaggerating  their  mental  pain ;  while  in 
most  cases  of  mania  the  patients  afBrm  they  are  quite  well,  probably 
better  than  they  ever  were  in  their  lives,  and  we  have  to  judge  of  their 
mental  condition  from  their  speech  and  actions,  which  become  to  us  the 
symptoms  of  the  disease. 

If  we  look  at  a  number  of  patients  who  are  all  classified  as  laboring 
under  mania,  we  see  at  once  that  there  is  a  very  great  difference,  indeed, 
between  different  cases.  Without  going  into  pathology  or  causation  at 
all,  the  outward  manifestations  show  not  only  far  greater  intensity  of 
morbid  action  in  different  instances,  as  is  the  case  in  all  diseases,  but 
a  difference  of  type  of  symptoms,  mental  and  bodily,  which  I  shall 
endeavor  to  assort  for  clinical  and  practical  purposes  into  varieties  of  the 
disease ;  it  being  understood  that  these  varieties  are  not  necessarily 
distinct  diseases  or  pathological  conditions,  but  merely  groups  of  similar 
symptoms  that  may  be  combined  with  other  groups,  or  may  be  different 
stages,  in  the  same  disease.  The  great  advantages  of  classifying  mania 
into  those  varieties  are,  that  thereby  a  student  is  less  confused  in  seeing 
patients  so  very  different  from  each  other,  and  more  especially  in  the  guide 
that  is  thus  obtained  in  treating  and  managing  patients.  The  varieties  I 
propose  to  describe  and  illustrate  by  clinical  cases  are — a.  simple  mania ; 
h.  acute  mania;  c.  delusional  mania;  d.  chronic  mania;  e.  ephemeral 
mania  {mania  transitoria);  and/,  homicidal  mania. 

Simple  Mania. — When  a  man  of  common  sense,  who  has  been  of  the 
ordinary  type  as  to  conduct,  demeanor,  and  speech,  undergoes,  without 
outward  cause,  such  an  intellectual  change  that  he  becomes  loquacious, 
talking  constantly  to  every  one  Avho  will  listen  to  him  about  anything 
under  the  sun,  especially  his  own  private  affairs — when  his  judgment  is 
manifestly  not  to  be  depended  upon,  and  his  vicAvs  as  to  himself,  his 
prospects,  his  capacities,  mental  and  bodily,  and  his  possessions  mani- 
festly exceed  what  the  facts  Avarrant — when  he  becomes  fickle,  restless, 
unsettled  in  his  conduct,  and  foolish  in  his  manner — when  he  acts  without 
motive  and  Avithout  aim — Avhen,  in  fact,  his  common  sense  has  gone,  and 
his  power  of  self-control  has  become  manifestly  lessened,  and  when  this 
lasts  for  days  or  weeks,  we  say  he  labors  under  simple  mania.  This 
condition  Avould  seem  at  first  sight  an  easy  one  to  describe.  But  it  is 
not  so ;  for  though  it  seems  simple,  yet,  Avhen  Ave  come  to  analyze  the 
mental  faculties  involved,  and  hoAV  they  are  affected  in  different  cases, 
Ave  find  an  immense  variety  of  combinations.  No  one  case  is  quite  like 
another  any  more  than  any  one  man's  mental  development  is  like  that  of 
another.  A  condition  of  morbid  mental  exaltation  may  exist,  and  I 
belicA^e  does  occur,  among  persons  of  a  nervous  heredity,  far  more  fre- 
quently than  is  commonly  supposed  in  slight  forms  that  are  not   con- 


126  STATES    OF    MENTAL    EXALTATION. 

fiidered  insanity  at  all.  I  would  go  the  length  of  placing  the  "lively 
moods"  to  which  some  people  are  subject  in  the  category  of  a  direct  kin- 
ship to  simple  mania,  just  as  I  would  place  the  "dull  moods"  of  some 
people  among  the  relationships  of  simple  melancholia. 

The  longer  I  live,  the  more  I  am  impressed  with  the  fact  that  some 
of  the  important  acts  in  the  lives  of  certain  persons  are  the  result  of 
brain  conditions  that  cannot  be  reckoned  as  being  quite  normal.  The 
men  whom  one  knows  as  subject  to  restless,  energetic,  boisterous  fits 
lasting  for  weeks,  who  do  childish,  extravagant,  or  foolish  things  at  these 
times,  whose  natural  peculiarities  are  then  much  exaggerated,  and  whose 
common  sense  seems  to  ebb  and  flow  in  an  unaccountable  way,  are  of 
this  class.  If  we  inquire  into  the  fiimily  history  of  those  persons,  we 
are  almost  sure  to  find  a  nervous  strain.  We  will  usually  find,  too,  that 
the  more  we  take  to  studying  the  practical  psychology  of  our  fellow-men 
from  the  point  of  view  of  heredity  and  brain  function,  the  more  will 
those  peculiarities  impress  us  as  being  the  same  in  nature,  but  less  in 
degree  than  those  greater  mental  peculiarities  that  we  call  insanity.  Not 
that  for  a  moment  I  want  to  lessen  the  moral  responsibility  of  such  persons 
to  society  or  the  law,  or  to  confuse  the  great  assumption  that  underlies  all 
social  arrangements  and  all  law,  that  all  men  are  sane  and  responsible 
until  proved  by  good  evidence  not  to  be  so.  Still  the  field  I  am  indi- 
cating is  a  most  interesting  one  in  the  study  of  human  nature.  I  have 
known  great  fortunes  lost  and  even  made ;  great  enterprises  undertaken ; 
great  speeches  made;  great  reputations  impaired;  unsullied  characters 
stained  irretrievably  in  the  public  eye;  ancient  families  degraded;  mar- 
riages contracted,  adulteries  committed,  and  unnatural  crimes  perpe- 
trated by  men  and  women  whom  I  considered  to  be  laboring  under  mild 
attacks  of  simple  mania,  but  whom  the  world  in  general  simply  looked 
on  fi-om  the  ethical  and  legal  point  of  view.  Those  persons  were  the 
victims  of  "the  tyranny  of  their  organization;"  yet  our  medico-psycho- 
logical knowledge  will  have  to  be  far  more  accurate  and  more  widely 
diffused  before  we  can  save  them  from  it  or  its  direct  consequences.  In 
such  cases,  we  find  that  at  a  certain  period  in  their  lives  a  mental  change 
took  place.  In  some  way  their  "characters"  underwent  an  alteration. 
In  my  experience,  by  far  the  greater  number  of  the  cases  of  "moral 
insanity"  were  of  this  kind.  Most  of  Pritchard's  cases  of  moral  insanity 
I  look  on  as  examples  of  simple  mania.  Of  course,  I  do  not  mean  those 
cases  where  no  morals  had  ever  come  to  a  person  by  heredity,  education, 
or  example,  or  where  the  morals  and  self-control  had  been  deliberately 
destroyed  by  the  mode  of  living. 

I  knew  a  gentleman,  C.  A.,  who  was  famed  in  his  neighborhood  for 
his  prudence,  probity,  and  devotion  to  business,  for  his  wisdom,  morality, 
and  religion,  who,  at  a  certain  period  of  his  life,  after  middle  age  had 
come  on,  underwent  a  total  change.  He  became  rash,  indiflerently 
honest,  utterly  careless  of  his  business,  foolish  in  his  schemes,  very 
doubtfully  moral,  and  careless  of  religion.  He  changed  in  his  mode  of 
dressing,  in  the  company  he  kept,  and  his  way  of  diving.  His  affairs 
got  entangled,  and  he  lost  a  fortune  by  foolish  speculation,  this  being 
entirely  new  to  him.  Yet  he  mingled  in  society  all  the  time;  never  said 
a  particularly  foolish  thing;  transacted  business  in  a  large  way  of  the 


STATES    OF    MENTAL    EXALTATION.  127 

utmost  importance  to  himself  and  others ;  and  I  should  have  been  very 
sorry  indeed  for  any  one  who  had  called  him  insane  to  his  face,  or  taken 
steps  to  abridge  his  personal  liberty,  or  deprive  him  of  his  civil  rights 
as  a  citizen.  No  jury  in  the  empire  but  would  have  held  him  sane,  and 
no  judge  but  would  have  made  his  case  a  text  for  a  homily  on  the 
danger  of  medical  views  in  regard  to  insanity  and  the  liberty  of  the 
subject.  I  am  never  more  impressed  with  the  difference  between  ap- 
pearance and  reality  than  when  I  hear  a  judge  dogmatically  lay  down 
the  law  in  regard  to  intricate  points  of  human  conduct  and  motive,  and 
remember  that  the  man's  education  was  probably  a  most  one-sided  one, 
with  not  an  atom  of  science  in  it,  and  not  a  suggestion  of  the  study  of 
brain  function,  that  his  training  was  got  in  an  atmosphere  where  every 
act  is  assumed  to  have  "a  motive;"  where  the  worst  motives  are  com- 
monly assumed,  and  all  men  are  supposed  to  have  bad  motives  more  or 
less.  I  venture  to  say  that  you  will  not  have  been  in  practice  for  a  year 
before  you  will  have  seen  many  men  and  women  whose  conduct  will  be 
utterly  inexplicable,  except  on  the  theory  that  it  is  the  result  of  their 
brain  condition,  "motives,"  as  ordinarily  understood,  having  nothing  to 
do  with  it.  Well,  C.  A.  got  through  his  fortune,  ruined  his  reputation, 
and  scandalized  and  estranged  his  friends,  all  without  any  "motive"  of 
the  ordinary  kind;  and  all  this  came  on  suddenly  and  in  entire  opposi- 
tion to  the  whole  tenor  of  his  life,  and  to  every  principle  that  had  ever 
held  sway  over  him  for  twenty  years.  Yet  legally  sane  he  was,  just 
because  the  brain  change  that  I  assume  was  the  cause  of  all  this  did  not 
go  far  enough  to  make  him  lose  his  self-control  entirely,  and  to  act  mani- 
festly as  a  lunatic.  Yet  can  any  one  who  has  studied  mind  from  the 
brain  point  of  view  doubt  that  the  man's  mental  acts  and  conduct  during 
his  changed  period  were  morbid,  and  the  result  of  morbid  brain  action? 
And  this  conclusion  was  vastly  strengthened  by  the  fact  that  his  heredity 
was  a  nervous  one,  he  coming  of  a  family  in  Avhich  insanity  and  eccen- 
tricity had  been  prevalent,  and  that  he  procreated  epileptic  children. 
And,  by  tracing  his  future  life,  we  find  that  still  without  any  "motive," 
he  again  changed,  and  settled  down  into  a  quiet-going,  slightly  senile 
man,  Avith  the  fine  edge  of  his  faculties  and  dispositions  somewhat  taken 
off.  In  this,  as  in  several  others  similar  that  I  have  met  with,  such  a 
mild  attack  of  mania  came  on  shortly  after  widowhood.  I  have  seen 
this  in  both  sexes.  My  idea  is  that  this  was  not  a  coincidence,  but  that 
the  sudden  deprivation  of  sexual  intercourse  had  something  to  do  with 
it  in  this  case  as  an  exciting  cause. 

Such  is  an  example  of  simple  mania  in  its  mildest  form,  not  being 
reckoned  insanity  at  all  by  the  law  or  by  society.  I  am  quite  sure  that 
you  will  meet  with  many  similar  cases  in  your  practices  if  you  look  at 
human  conduct  from  the  medico-psychological  point  of  view.  And  you 
may  perhaps  save  a  fortune,  or  a  reputation  sometimes,  and  will  cer- 
tainly save  much  uncharitable  recrimination  and  useless  indignation  on 
the  part  of  relations  by  putting  them  in  possession  of  your  knowledge. 
When  I  am  consulted  in  such  cases  now,  I  recommend  a  long  sea  voyage 
in  a  slow  ship,  or  a  change  of  residence  for  a  time,  and  try  and  get 
business  matters  settled  on  some  sort  of  sure  footing,  so  that  unsafe 
speculation  or  falling  into  the  hands  of  scoundrels  may  be  avoided. 


128  STATES    OF    MENTAL    EXALTATION. 

There  is  no  class  of  case  where  harpies  seem  to  fix  on  a  man  so  inevit- 
ably as  in  this.  Such  men  are  easily  led  by  adroit  and  unprincipled 
people,  Avho  flatter  them,  and  take  advantage  of  their  weakness.  The 
sort  of  persons  whom  the  man  in  his  "right  mind"  would  never  have 
associated  with  get  round  him  then.  He  tends  to  seek  persons  in  a  loAver 
social  and  ethical  position,  and  very  often  the  loss  of  lys  self-control 
is  shown  by  an  excessive  use  of  stimulants,  or  by  frequenting  bad  company, 
both  being  mere  symptoms  of  his  mental  disorder.  The  lower  and  baser 
parts  of  a  man,  kept  under  before,  now  come  uppermost.  Especially  is 
excitation  of  the  sexual  desire  and  disregard  of  morals  and  appearances 
in  gratifying  it  most  common.  I  have  found  this  to  exist  in  nine-tenths 
of  such  cases.  I  once  saved  a  business  and  a  reputation  by  getting  a  man 
in  the  beginning  of  an  attack  of  mild  mania  to  take  a  partner,  give  up 
business  meantime,  go  to  spend  a  year  with  a  friend  on  a  sheep  farm  in 
Australia,  live  out  in  the  open  air,  take  much  (but  not  too  much)  exercise, 
eat  little  animal  food,  and  take  bromide  of  potassium  in  twenty  grain 
doses  three  times  a  day.  This,  in  fact,  sums  up  about  all  I  can  tell  you 
in  regard  to  treatment.  The  great  difficulty  is  that  such  patients  do  not 
know  that  there  is  anything  wrong  with  them  and  will  not  believe  it,  in 
fact  are  often  most  indignant,  and  quarrel  with  you  if  such  a  thing 
is  hinted  at.  They  sometimes  look  well,  but  they  do  not  sleep  well,  and 
all  of  them  are  restless,  and  often  worn-looking.  They  often  eat  twice 
or  thrice  as  much  as  usual,  and  digest  their  food  well.  They  often 
have  their  bowels  moved  twice  or  thrice  a  day,  even  if  naturally  of  a 
costive  habit.  Their  tastes  usually  change.  They  lose  their  fine  feelings 
and  delicate  perceptions  of  things  in  taste  and  smell  and  sensibilities.  I 
have  known  a  man  who  needed  to  use  highly  magnifying  spectacles  to  be 
able  to  do  without  them,  and  even  be  able  to  read  small  print,  when 
passing  through  an  attack  of  simple  mania.  In  fact,  I  knew  a  man  who, 
as  the  morbid  brain  excitement  gradually  passed  away,  had  to  use 
spectacles  of  greater  and  greater  magnifying  power.  The  body  tempera- 
ture is  always,  I  have  found,  higher  by  about  .5°  or  1°  during  such  an 
attack. 

This  case  was  one  of  great  interest,  from  the  natural  power  of  the 
brain  affected.  C.  B.  was  a  man  of  very  high  intellectual  and  scientific 
attainments,  with  a  heredity  to  the  neuroses,  of  a  sanguine  temperament 
and  robust  bodily  constitution,  great  mental  energy  and  acuteness,  who 
was  prudent,  discreet,  and  held  the  opinions  of  others  in  great  respect. 
He  had  written  much  and  done  very  good  work.  At  the  age  of  forty-five 
he  lost  his  wife,  whom  he  had  sleeplessly  nursed,  and  within  a  week  pro- 
posed marriage  to  another  lady,  became  excited,  took  two  girls  out  of  a 
brothel,  got  lodgings  for  them,  tried  to  reform  them,  spent  money  on 
them,  prayed  with  them,  and  slept  with  one  of  them,  intending,  as  he 
said,  to  make  her  his  wife.  And  he  did  some  work  in  a  sort  of  sporadic 
way,  not  sticking  to  anything.  He  slept  little,  and  kept  very  late  and 
irregular  hours.  Then  he  developed  great  brilliancy  and  social  faculty, 
for  which  he  had  never  been  distinguished  before.  He  especially  liked 
ladies'  society,  and  he  was  witty,  clever,  and  had  a  miraculous  memory, 
indeed  a  better  memory  than  he  ever  had  before.  (I  knew  one  man  who, 
as  he  was  passing  into  mania,  would  repeat  a  whole  play  of  Shakespeare 


STATES    OF    MENTAL    EX  ALT  ATIOIST.  129 

or  a  book  of  Milton,  which  when  well  he  could  not  do.)  He  could  quote 
long  passages  from  every  author  he  had  ever  read.  Then  he  began  to 
evolve  wonderful  schemes  of  all  sorts — not  quite  insane  schemes,  but 
very  nearly  so.  He  got  irritable  with  those  who  opposed  him,  and  said 
they  persecuted  him.  He  went  and  called  on  all  his  casual  acquaintances 
of  any  note,  and  made  new  acquaintances  on  slight  cause.  He  had  been 
very  fond  of  his  children  before,  and  now  he  spoke  much  of  his  affection 
for  them,  but  really  he  neglected  them.  He  quarrelled  with  his  relatives 
because  they  remonstrated  with  him  and  tried  to  control  him.  His  next 
stage  was  a  morbid  expansive  benevolence.  He  gave  away  his  money 
foolishly  to  the  poor,  or  to  anybody  whom  he  thought  needed  it.  He  pro- 
pounded to  the  philanthropists  marvellous  plans  to  terminate  the  world's 
misery.  He  went  one  night,  with  his  Bible  in  his  hand,  to  a  brothel  to 
convert  its  inmates  from  the  error  of  their  ways ;  but,  after  reading  and 
prayer,  the  vice  he  hated  was  in  one  short  hour 

"  Endured,  then  pitied,  then  embraced," 

and  he  had  to  leave  his  Bible  in  pledge,  as  he  had  not  sufficient  money  in 
his  pocket!  All  those  things  he  spoke  of  freely.  Soon  after  this  bis 
conduct  became  so  uncontrolled  that  he  Avas  certified  as  insane  and  sent  to 
the  Asylum.  But  he  had  succeeded  in  wasting  nearly  all  his  available 
means.  When  he  arrived  he  was  indignant,  and  made  out  that  his  friends 
had  ruined  his  prospects  by  placing  him  improperly  in  a  "madhouse." 
But  his  indignation  was  transient  and  skin-deep.  He  soon  entered  into 
the  life  of  the  place.  He  was  an  admirable  and  interesting  talker,  a 
copious  and  sparkling  author  in  the  Morningside  Mirror,  a  hearty  if  not 
an  elegant  dancer,  a  great  walker,  a  scientist,  and  a  devoted  admirer  of 
all  the  fair  sex,  making  love  indiscriminately  to  lady  patients,  nurses, 
kitchen  maids,  and  paupers.  And  yet  he  could  propound  maxims  as  wise 
as  Solomon's  Proverbs,  and  he  was  a  stern  and  sarcastic  censor  of  morals 
in  others.  But  he  had  no  common  sense ;  and  he  could  not  help  making 
a  fool  of  himself  if  he  had  the  chance.  He  could  not  be  trusted  any- 
where out  of  the  Asylum.  He  talked  about  his  most  private  concerns  to 
any  one  who  would  listen  to  him.  He  was  very  credulous,  and  in  conduct 
he  showed  small  realization  of  the  difference  between  meum  and  tuum,  or 
of  the  sanctity  of  the  virtues  generally.  His  memory  was  prodigious ; 
and  he  was  never  at  rest.  His  sexual  appetites  were  strong,  but  not 
really  so  strong  as  his  erotic  imaginations  and  likings.  He  told  most 
disgusting  stories  "for  a  moral  purpose"  to  others,  and  he  was  better  up 
in  the  sexual  history  of  great  men  than  any  man  I  ever  knew.  He 
never  got  incoherent;  he  could  always  control  himself  for  a  short  time. 
He  was  always  ready  with  most  plausible-looking  excuses  for  his  innumer- 
able peccadilloes.  "Why  should  I  not  kiss  that  girl  and  write  her  love 
letters  ?  I  want  to  be  kind  to  all  persons,  and  don't  you  tell  me  to  make 
the  best  of  my  present  position  ?  If  I  lose  my  temper  sometimes,  is  not 
the  natural  indignation  at  the  way  my  friends  have  used  me  sufficient  to 
account  for  it? "  etc.  After  having  one  morning  abused  me  most  heartily, 
he  sent  towards  evening  a  letter  addressed  "  Immediate.  The  sun  has  not 
gone  down.  Morningside.  From  my  prison,  where,  like  Joseph,  and 
Peter,  and  Paul,  I  was  put  on  false  accusations.     My  dear  Clouston,  I  beg 

9 


130  STATES    OF    MKXTAL    EXALTATION. 

yonr  pardon  for  speaking  to  you  and  of  you  as  I  have  done.  I  want  some 
liberty.  Try  and  let  some  patients  out,  and  you  will  become  the  greatest 
man  of  the  day.  Give  the  exciteil  ones  sedatives  like  tobacco  or  better 
food.  Dismiss  such  men — et  audi  alteram  partem,  that  is,  hear  my 
version  of  things.  Let  me  get  to  town  to-day.  I  need  a  change.  Think 
who  I  am.  Since  1847  the  friend  of  Thomas  Cai-lyle  and  Alfred 
Tennyson;  of  Owen  since  1838;  of  Darwin,  of  Sir  John  Richardson, 
Rae,  etc,  etc,  etc"  (He  had  casually  met  these  men  or  called  on  them 
as  he  was  becoming  ill.) — **  Yours  ever." 

**JP.iS. — Why  have  you  not  shown  me  your  children?  I  do  not  bite, 
I  only  bark. 

**/*./*.«S*. — ^Read  this  to  anv  one  who  mav  be  concerned."  . 

Persons  laboring  under  simple  mania  are  always  in  the  right,  and  are 
verv  sensitive  to  criticism  and  indignant  at  it.  There  is  much  of  what 
one  can  only  call  cunning.  C.  B.  could  control  himself  for  short  periods 
when  he  wished,  or  when  self-control  was  to  bring  any  advantage :  he 
would  pretend  to  be  most  friendly  with  the  powers  that  be  in  the  Asylum 
before  their  faces,  and  then  turn  and  abuse  them  behind  their  backs.  He 
would,  to  strangers,  most  cleverly  make  things  appear  exti-eme  hartlships 
that  he  did  not  feel  as  such.  He  ate  enormously  and  slept  badly,  but  did 
not  fell  off"  very  much  in  flesh. 

After  six  months  he  was  so  much  better  ^at  he  was  sent  to  a  distant 
part  of  the  country,  where  he  stayed  for  far  too  short  a  time  He  made 
an  unsuitable  marriage  with  a  woman  below  himself  in  social  station  and 
education,  had  children  by  her,  but  soon  got  tired  of  her,  saying  she  was 
a  prostitute.  He  then  lived  an  eccentric  life  for  twelve  years,  getting 
syphilis,  as  he  said,  from  **  using  an  unclean  handkerchief  I "  At  the  end 
of  that  time  he  had  another  attack  of  simple  mania  of  the  same  general 
character  as  the  one  described,  but  all  thie  symptoms  more  severe.  He 
was  more  incoherent,  less  brilliant,  less  interesting,  more  disgustingly 
immoral — ^his  brain,  in  feet,  had  the  fine  edge  of  all  its  qualities  taken  off. 
He  died,  after  a  few  years,  still  maniacal,  but  with  some  of  the  mental 
enfeeblement  of  dementia. 

Such  a  patient  must  be  r^arded  as  suffering  from  simple  mental  ex- 
altation with  mild  excitement,  the  result  of  a  hereditary  instabili^  of 
brain.  My  experience  is  that  brain-work  and  education  tends  towards 
this  condition  in  those  predisposed.  One  cannot  speak  dogmatically,  but 
I  think  that  if  such  a  man's  brain  had  never  been  highly  educated,  or  if 
he  had  not  taken  to  intellectual  work,  or  even  if  his  wiJFe  had  lived,  he 
never  might  have  developed  the  morbid  brain  elevation  at  all.  It  might 
have  remained  all  his  life,  as  it  had  done  for  forty-five  years,  a  mere 
potentiality.  Such  cases  are  most  difficult  to  treat  and  manage.  They 
will  not  be  controUed  outside  an  asylum,  where  they  create  scandal  and 
waste  money,  yet  it  is  for  a  long  time  impossible  to  certify  them  as  insane; 
and  when  sent  to  asylums  it  is  undoubtedly  hard  on  them,  for  they  are 
SQQsitive  and  irritable  and  capable  of  enjoying  life  to  a  large  extent. 
Such  attacks  are  usually  over  six  months  in  duration,  but  I  have  seen 
two  very  transitory  and  pass  away  in  six  weeks.  I  do  not  know  any 
method  as  yet  to  influence  fevorably  such  morbid  energizing  of  the  brain 


STATES    OF    MENTAL    EXALTATION".  131 

except  quiet,  fresh  air,  non-stimulating  food,  warm  baths  at  night,  and 
bromide  of  potassium. 

The  following  case,  of  short  duration,  was  undoubtedly  benefited  by- 
restraint  in  an  asylum.  It  was  that  of  C.  C,  a  member  of  a  learned 
profession,  aged  fifty-nine,  of  a  sanguine  temperament,  and  cheerful  and 
frank  disposition,  and  good  bodily  health,  good  habits,  and  no  hard  work. 
He  had  been  morbidly  excited  in  mind  on  four  or  five  previous  occasions, 
the  excitement  passing  oif  in  six  weeks,  being  treated  by  his  being  sent 
off  to  a  lonely  country  place  to  "walk  it  off"  among  the  hills.  There 
was  no  admitted  or  known  heredity  (such  facts  in  family  histories  are 
kept  very  secret  and  are  soon  forgotten,  so  that  they  are  often  really  not 
known  to  the  younger  members  of  a  family),  except  that  his  mother  had 
been  in  a  state  of  senile  dotage  for  ten  years  before  her  death  at  a  very 
advanced  a^e.  Six  weeks  before  admission  he  had  become  chano;ed  in 
disposition,  altered  in  conduct,  unsettled,  much  elevated,  always  talking 
about  the  Turco-Servian  war  that  was  going  on  then,  restless,  sleepless, 
changed  in  his  appetites  and  tastes  for  food,  and  he  began  to  dress  in  an 
entirely  different  way  from  what  was  natural  to  him.  In  his  case  the 
most  striking  alteration  was  in  his  truthfulness.  Naturally  a  truthful 
man,  when  his  illness  began  he  took  to  telling  lies  by  wholesale  about 
everything,  and  for  no  purpose  or  "motive."  He  was  boastful  to  ab- 
surdity, bragging  of  qualities  nearly  the  opposite  to  those  needed  in  his 
profession.  This  human  nature  tendency  to  be  very  proud  of  things  out 
of  one's  line — the  lawyer  of  his  medical  skill,  the  parson  of  his  worldly 
wisdom — you  will  find  in  an  exaggerated  degree  in  mania.  He  was  a 
marvellous  swimmer,  a  splendid  boxer  ;  he  would  dilate  with  circum- 
stantial detail  on  the  numbers  of  expert  swordsmen  he  had  overcome  and 
killed,  and  on  the  pugilists  he  had  thrashed  to  within  an  inch  of  their 
lives.  He  said  he  was  going  out  to  the  war,  and  would  soon  be  made 
the  general  of  the  Servians,  and  he  actually  purchased  some  appropriate 
weapons.  Yet  there  was  a  little  method  in  his  madness,  for  he  was  a 
little  careful  about  who  he  told  those  wonderful  tales  to,  and  his  manner 
of  telling  them  was  not  quite  that  of  a  lunatic  who  fully  believed  them. 
He  drank  too  much,  and  his  habits  were  not  orderly  or  cleanly.  An 
hour  before  he  was  taken  to  the  Asylum  he  had,  to  some  persons,  of 
whom  I  was  one,  whom  he  thought  congenial  spirits,  told  his  best  stories, 
and  had  exhibited  a  mixture  of  extravagance,  lies,  boastfulness,  and  ob- 
scenity that  quite  convinced  two  of  the  company  (doctors  there  to  examine 
him)  that  he  was  very  insane,  and  they  certified  him  at  once.  From  the 
way  he  had  been  talking,  those  who  took  him  to  the  Asylum  were  pre- 
pared for  a  desperate  resistance.  But  there  was  nothing  of  the  kind. 
With  a  verbal  "protest,  and  a  manner  as  meek  as  Moses,  with  no  resist- 
ance and  no  fight  at  all,  this  Avondrous  pugilist  went  to  the  asylum.  He 
collapsed  at  once,  and  his  whole  effort  was  to  explain  away  his  conduct, 
and  apologize  for  his  language.  It  seemed  to  act  like  a  charm  on  him, 
and  to  restore  much  of  his  power  of  self-control.  He  again,  and  at  once, 
assumed  the  speech  and  manner  of  an  elderly  parson — this  pugilist  of  an 
hour  before.  And  he  never  again  indulged  in  quite  such  speech,  or  ex- 
hibited such  conduct,  though  he  dressed  queerly  for  a  few  weeks,  did  not 
sleep  well,  and  was  elevated  in  his  demeanor.     He  tried  hard  to  attach 


132  STATES    OF    MENTAL    EXALTATION. 

unreal  meanings  to  his  tales,  and  to  apologize  for  his  extravagant  conduct. 
In  three  months  he  was  quite  well,  and  has  kept  quite  well  since.  The 
sudden  pulling  of  himself  up  by  a  patient  on  being  taken  to  an  asylum  is 
often  seen,  both  in  mania  and  in  melancholia,  but  it  does  not  always  last. 
The  brain  pace  breaks  out  again,  and  sometimes  far  harder  than  before, 
because  at  home,  perhaps  before  children,  as  much  self-control  as  possible 
is  exercised,  while  in  an  asylum  a  man  sometimes  thinks  there  is  no  ob- 
ject in  exercising  it,  and  does  not  do  so. 

In  other  cases  of  simple  mania  a  morbid  vanity  is  exhibited,  as  in  the 
following  case.  I  have  no  doubt  that  the  weak  forms  of  normal  character 
are  those  that  are  usually  exaggerated  in  simple  mania :  C.  D.,  a  trades- 
man, was  sent  as  a  patient  to  the  Royal  Edinburgh  Asylum,  and  at  first 
he  seemed  to  be  merely  a  talkative  and  egotistical  old  gentleman.  But 
it  soon  appeared  that  authorship,  and  poetry  in  particular,  Avas  his  special 
weakness  ;  while,  along  with  this,  there  was  a  peacock-like  vanity  in  dress 
and  demeanor  that  was  very  ludicrous.  By  a  pompous  manner,  a  sesqui- 
pedalian speech  intended  to  be  impressive,  a  combination  of  the  juvenile 
and  the  Byronically  poetic  in  dress,  and  a  very  big  book  always  carried 
under  his  arm,  he  showed  his  morbid  vanity.  He  was  most  touchy  of 
being  interrupted  in  his  long  speeches,  and  he  tried  to  be  very  withering 
in  his  contempt.  He  used  to  write  me  a  letter  of  fifty  pages  of  foolscap 
in  the  prosiest  style  if  he  had  a  simple  matter  to  bring  under  my  notice. 
Indeed,  his  speeches,  which  he  tried  to  inflict  on  me  every  day,  used  to 
try  me  pretty  nearly  up  to  the  point  of  my  own  power  of  endurance, 
though  I  am  pretty  well  seasoned  in  the  art  of  bearing  fools  gladly.  His 
poetry  was  trash,  which  he  produced  by  the  ream,  thinking  it  was  equal 
to  Shakespeare's,  and  he  tried  to  read  it  with  due  dramatic  eifect  to  the 
ladies  in  the  drawing-room  in  the  evenings.  Yet,  with  all  this,  he  was 
not  incoherent.  He  had  periods  of  intensified  excitement,  when  he  would 
scold.  He  was  very  thin  when  admitted,  and  his  nervous  and  nutritive 
power  and  tone  low,  so  I  fed  him  well,  gave  him  a  liberal  allowance  of 
good  London  porter,  extra  milk,  and  cod-liver  oil,  and  insisted  on  his 
being  in  the  open  air  most  of  the  day.  He  got  fat ;  and  as  this  took 
place  his  foolish  vanity  and  excitability  diminished,  and  he  grew  into 
a  moderately  rational  human  being,  who  left  the  asylum  with  the  full  in- 
tention of  returning  to  his  business.  But  the  loss  of  external  control 
seemed  like  taking  oif  the  governors  of  a  steam-engine ;  he  got  thin, 
poetic,  and  morbidly  vain,  and  had  to  be  sent  to  another  asylum,  where 
surely  they  did  not  give  him  as  much  paper  as  we  did,  for  he  abused  the 
place  most  heartily,  and  wanted  badly  to  come  back  to  Morningside,  but 
we  had  no  room  for  him,  and  he  died  in  a  year  or  two,  still  insane. 

I  have  met  with  cases  of  simple  mania  where  the  lack  of  controlling 
power  was  seen,  not  so  much  .in  speech  or  ordinary  conduct  as  in  want 
of  muscular  inhibition.  I  had  a  young  lady,  C.  E.,  under  my  care  once, 
who  came  of  a  very  nervous  family,  and  whose  brother's  case  I  have 
referred  to  (p.  60),  as  exhibiting  such  morbid  indecision  and  paralysis  of 
volition  that  he  could  not  make  up  his  mind  which  stocking  to  put  on  for 
half  an  hour.  She  seemed  perfectly  well  when  one  spoke  to  her,  but 
when  left  alone  she  would  make  faces,  jump  about,  tear  her  clothes,  turn 
heels  over  head,  scream,  pick  her  skin,  and  masturbate  apparently  auto- 


STATES    OF    MENTAL    EXALTATION.  133 

matically  without  much  erotic  intent  or  much  sexual  feeling.  In  the 
midst  of  all  this,  if  one  addressed  her  she  would  sit  up  and  talk  as  in- 
telligently and  quietly  as  possible.  She  had  no  delusions,  no  tendency 
to  violence,  and  was  gentle  and  lady-like.  She  came  into  the  asylum  as 
a  voluntary  patient,  and  declaimed  that  she  could  not  restrain  those  move- 
ments. Like  chorea,  they  came  on  in  an  aggravated  way  at  the  menstrual 
periods.  They  were  unlike  choreic  movements  in  their  real  character, 
being,  if  one  might  use  a  contradiction  in  terms,  automatically  volitional. 
She  did  not  sleep,  and  could  not  employ  herself  for  any  length  of  time. 
She  recovered  from  the  first  of  these  attacks  in  a  few  months,  but  then 
had  a  more  severe  one,  over  which  no  treatment  had  any  permanent 
effect,  and  she  got  thinner  and  more  attenuated,  and  died  of  exhaustion 
in  about  two  years.  She  was  free  from  delusions,  and,  in  a  way,  intel- 
lectually sound  up  to  the  last,  during  the  periods  when  she  picked  her- 
self up.  Every  sort  of  treatment  was  adopted,  everything  to  fatten  and 
improve  the  nerve  tone  that  we  could  think  of — cod-liver  oil,  maltine,  the 
phosphates,  hypophosphites,  arsenic,  strychnine,  etc.  All  the  usual  seda- 
tives and  narcotics  were  tried — the  bromides,  opium,  henbane,  cannabis 
indica,  lupuline,  camphor.  She  was  anaesthetized  by  ether  and  chloro- 
form.    She  had  blisters,  warm  baths,  exercise  almost  to  exhaustion,  etc. 

That  Avas  an  extreme  and  pure  example  of  a  symptom  which  we  see 
commonly  enough  in  mania,  viz.,  automatic  coordinated  movements  that 
are  ordinarily  voluntary,  but  result  evidently  from  morbid  exaltation  of 
function  in  the  highest  motor  centres  in  the  convolutions.  It  is  a  mus- 
cular mania,  the  intellectual  and  volitional  power  being  comparatively 
intact,  but  the  highest  ideo-motor  inhibitory  centres  being  paralyzed. 
It  was  a  curious  fact  that  her  brother  should  have  been  affected  in  such 
a  different  and  psychologically  contrasted  way — in  the  one,  the  will  not 
being  able  to  put  the  muscles  into  action ;  in  the  other,  not  being  able  to 
stop  them. 

I  said  that  simple  mania  assumes  the  form  of  "moral  insanity"  at 
times,  without  apparent  intellectual  aberration.  The  system  of  checks 
on  inclination,  doing  duty  for  its  own  sake,  and  efforts  after  the  good, 
which  by  the  constant  strivings  of  years  has  become  a  habit,  and  consti- 
tutes the  man's  moral  character,  sometimes  vanishes  like  the  early  dew 
at  the  beginning  of  an  attack  of  mania.  I  shall  give  an  example.  C.  F., 
a  lady  of  good  education,  good  morals,  refined  disposition,  and  lady-like 
tastes,  had  several  attacks  of  mental  disease,  of  which  the  following  were 
always  the  symptoms :  She  slept  much  less  than  usual,  and  got  thinner. 
Her  expression  of  face  changed.  Instead  of  being  a  pleasant-looking 
Avoman,  her  features  acquired  a  coarser  look.  She  ate  twice  as  much, 
and  lost  the  delicate  Avays  of  a  lady.  She  lied,  stole,  whored,  and  took 
pleasure  in  annoying  or  hurting  every  person  she  came  across.  She  was 
cruel  to  animals.  She  was  such  a  blister  and  firebrand  that  she  could 
live  in  no  private  house  Avith  others,  and  in  the  asylum  she  could  set  up 
ten  patients  in  as  many  minutes.  She  had  the  most  extraordinary  in- 
stinct in  finding  out  the  weak  points  of  her  fellow-creatures  I  ever  saw, 
and  she  remorselessly  used  this  for  their  annoyance,  this  being  her  chief 
delight.  She  did  not  court  a  fight,  but  never  declined  one  Avith  any  per- 
son Avhom  she  had  roused  to  fury,  enjoying  it  too  ;  and  yet,  with  all  this, 


134  STATES    OF    MENTAL    EXALTATION. 

she  was  plausible,  always  with  a  ready  excuse  for  her  scrapes,  could  make 
herself  most  agreeable  at  an  evening  party,  and  would  have  defied  any 
doctor  to  find  facts  indicating  insanity  in  an  hour's  conversation.  It  was 
only  by  watching  her  conduct  that  such  facts  could  be  got,  and  she  could 
be  certified.  She  was  such  a  nuisance  that  asylums  passed  her  on  from 
one  to  the  other  as  too  troublesome  to  keep,  though  she  seldom  got  into 
a  rage  or  became  outwardly  excited.  And  all  this  came  on  her  at  inter- 
vals like  another  disease,  passing  off,  and  leaving  her  the  same  refined, 
moral,  and  pleasant  lady  she  had  ever  been. 

I  had  once  under  my  care  a  girl,  C.  G.,  age  17,  the  daughter  of  a 
gentleman,  her  mother  being  intemperate.  Had  been  well  brought  up, 
and  up  to  within  a  week  of  her  admission  to  the  asylum,  a  well-con- 
ducted girl.  She  was  of  a  robust  and  perhaps  rather  sensual  constitu- 
tion, who,  without  showing  any  previous  sign  of  insanity,  exqept  conduct 
that  was  called  wayward  and  disobedient,  left  her  home,  wandered  to 
where  some  workmen  lived,  in  a  lonely  place  many  miles  ofi",  and  passed 
the  night  with  them.  She  showed  no  other  signs  of  mania,  when  taken 
home,  than  utter  disregard  of  her  parents'  feelings,  bad  language  and 
violence  to  them,  Avant  of  right  feeling  of  any  sort,  and  threats  to  com- 
mit suicide.  Those  symptoms  were  recognized  as  constituting  insanity, 
and  she  was  sent  to  the  asylum.  This  state  of  matters  passed  off  in  a 
few  days,  and  she  became  apparently  Avell  in  all  respects,  except  that  she 
seemed  blunted  in  her  feelings,  incapable  of  applying  herself  to  any  work, 
and  at  times  sullen  and  stupid.  Her  catamenia  had  been  irregular,  and 
she  had  suffered  from  severe  headaches  before  the  attack.  She  remained 
free  from  excitement,  though  not  considered  well,  for  about  six  weeks, 
when,  just  before  menstruation,  and  preceded  by  frightful  cephalalgia, 
and  a  day  or  two  of  dulness  and  mental  torpor,  she  had  an  acutely 
maniacal  attack  of  great  violence,  coming  on  like  an  explosion,  and 
lasting  for  a  few  days.  She  had  three  of  those  within  a  month ;  then 
she  had  in  the  next  two  months  several  sullen,  stupid  attacks.  In  five 
months  she  recovered.  Each  maniacal  attack  was  accompanied  by  a  foul 
tongue,  deranged  bowels,  flushed  face,  and  total  loss  of  memory  and 
power  of  attention.  After  she  recovered,  she  had  no  recollection  of  any- 
thing that  had  occurred  during  the  attack.  Thus  the  immorality  and  the 
disobedience  and  disregard  of  her  parents'  wishes  were  clearly  shown  to 
have  been  symptoms  of  an  attack  of  simple  mania  which  preceded  the 
three  acute  attacks. 

I  once  saw  a  boy,  C.  H.,  of  14,  whose  father  was  a  drunkard,  wife- 
beater,  and  of  a  most  ungovernable  temper,  though  a  clergyman,  and  his 
mother,  a  doAvn-trodden,  rather  soft  woman,  his  elder  brother  being  just 
like  the  father.  His  father  used  to  make  C.  H.  drink  when  a  mere  boy, 
and  taught  him  to  smoke.  When  a  child,  he  had  been  of  a  most  ungov- 
ernable temper,  utterly  undisciplined  and  disobedient,  assaulting  his 
mother,  swearing,  shouting,  breaking  open  locks,  knocking  about  furni- 
ture, threatening  to  shoot  first  his  sisters  and  then  himself,  buying  a  pistol 
and  practising  with  it.  He  could  not  be  got  to  go  to  school,  or  to  do 
anything  useful.  His  habits  were  most  irregular.  He  would  stay  in 
the  house  for  weeks  at  a  time,  and  was  unsocial  and  unplayful.  When 
I  saw  him  he  was  quiet  and  apparently  reasonable.     He  was  a  delicate, 


STATES    OF    MENTAL    EXALTATION.  135 

nervous-looking  boy,  with  a  restless,  elevated  expression  of  eye  and  face. 
When  I  said  he  would  be  sent  to  sea  if  he  did  not  behave  better,  he  re- 
plied that  the  man  who  came  for  him  would  get  the  contents  of  his 
revolver.  I  recommended  him  to  go  and  travel  with  a  sensible  tutor, 
and  this  was  attended  with  benefit  to  him. 

Not  only  are  the  morals  affected,  but  the  Avhole  character  is  altered. 
I  have  seen  many  people  improved  vastly  in  certain  respects  during  a 
slight  attack  of  simple  mania.  I  knew  a  naturally  reserved,  proud,  un- 
social, rather  cantankerous,  selfish,  stupid,  miserly  man  become  for  a  time 
genial,  bright,  good-mannered,  and  generous  during  such  an  attack.  The 
changes  in  the  tastes,  instincts,  and  even  in  the  organic  appetites  are 
often  marked  and  most  peculiar.  Most  patients  do  not  like  the  same 
food  as  Avhen  in  health.  They  often  take  to  excessive  smoking,  and 
sometimes  to  drinking,  independently  of  their  habits  in  those  respects 
when  in  health.  The  delicate  likings  are  not  only  lost,  but  new  repug- 
nances develop  themselves,  and  former  feelings  of  friendship  are  com- 
monly altered  or  lost.  The  personal  habits  tend  to  become  untidy, 
slovenly,  and  dirty;  and,  by  the  way,  this  applies  to  melancholies  as  well, 
and  indeed  to  most  of  the  insane,  if  these  things  are  not  looked  to  and 
corrected. 

The  hifxher  intellectujil  tastes  also  chancre.  I  knew  a  man  who  could 
not  appreciate,  and,  as  a  matter  of  fact,  neglected  his  favorite  authors, 
taking  to  their  exact  opposites.  When  well,  he  read  Gibbon  and  Hume ; 
when  ill,  he  took  to  Burns  and  Swinburne. 

The  sort  of  brain  evolution  into  insanity  at  an  early  age,  which  the 
Germans  have  called  ^'■Primare  Ve7'riIcJctheit,"  in  which  changes  of  char- 
acter, foolish  insane  conceits,  waywardness,  unreasoning  extravagances, 
unsocialness.  gradually  develop  into  delusional  insanity  or  dementia,  may 
at  the  beginning  usually  be  classed  as  simple  mania.  The  JFolie  raison- 
nante  of  the  French  corresponds  in  a  general  way  to  the  milder  cases  of 
simple  mania. 

Simple  mania  is  very  often  the  first  stage  of  acute  mania,  which  we 
are  to  consider  next.  The  following  letters  of  a  young  unmarried  man, 
C.  J.,  who  naturally  was  of  a  modest,  rather  shy  disposition,  but  who 
had  for  a  month  labored  under  simple  mania  with  strong  exaltation  of  the 
nisus  generativus,  and  was  passing  into  acute  mania,  illustrates  the  mental 
condition  of  such  a  person.  The  first  two  letters  are  elevated  and  delu- 
sive, but  nearly  coherent ;  the  third,  a  month  afterwards,  very  much  more 
extravagant. 

EdinbuuGH,  'Ith  December. 
Dear  Dr  Clouston, — I  had  a  good  night's  sleep  last  night  after  the  pleasant  even- 
ing I  had,  and  feeling  sure,  after  the  kindness  I  have  met  with  here,  that  the  hest 
way  of  getting  a  perfect  cure  is  to  make  a  clean  breast  of  it,  I  now  try  to  do  so.     I 

believe  that  I  am  a  married  man,  and  that  a  lady  called  Miss ,  the  reputed 

daughter  of ,  is  really  my  wife,  further  that  she  has  had  children  by  me,  one 

of  which  is  dead.     I  believe  I  have  ten  children  by  her  still  alive,  three  of  whom  I 

used  to  believe  the  children  of  my  late  uncle ,  who  now  live  with  his  widow 

at ,  four  w-ho  were  brought  up  by ,  and  three  who  were  brought  up  by 

my  reputed  parents'  friends .     I  have  long  had  this  belief,  but  not  having  any 

proof  but  instinct  to  guide  me,  I  refrained  from  stating  it.  I  believe  it  is  true. 
iShould  it  not  be  so,  why,  it  onh'  proves  my  love  for  her  and  them,  and  I  feel  sure 
you  will  try  and  cure  me  of  the  delusion.  I  write  as  one  Christian  to  another  older 
and  more  experienced  one. — AVith  all  respect  and  confidence,  Yours . 


136  STATES    OF    MENTAL    EXALTATION. 


*I(h  Decemher. 


Dear  Dr  Clouston, — Tn  my  last  letter  1  put  the  cart  before  the  horse.     I  believe 

Mr (a  fellow  patient)  to  be  Duke  Constantine,  my  father  and  Miss to 

be ,  but  I  am  wrong  there  I  think.     Yours  faithfully . 

MORNINGSIDE,  EDINBURGH,  8//i  January, 

My  Dear  Old , — I  have  at  last  fallen  in  love  with  the  prettiest  girl  you 

ever  saw.  I  got  your  letter,  thanks,  old  man,  and  the  quotations  which  I  enjoyed, 
and  went  to  look  for  it  in  an  old  coat,  but  couldn't  find  it — well  but  this  girl  you 
know  I'm  a  bit  of  a  student  and  a  selfish  brute,  but  for  all  that  I  love  the  girl,  you 
may  call  a  thing  two  names,  but  it's  the  same  nearly  ? 

Now  the  fact  of  the  matter  is  they  are  so  uncommon  kind  to  a  fellow  here  women 
and  men,  it's  a  fact,  but  then  I  was  far  far  below  the  normal  point  of  sanitj',  that 
even  although  I  was  doomed  to  remain  here  all  my  natural  life,  I  could  do  it  with 

ups  and  downs,  but  you  see  this  girl, .     Were  I  pronounced  sane  enough  to 

be  out,  she  might  have  me.  The  fact  is, ,  I'm  such  another  uncommon  agree- 
able fellow  at  times,  but  then  it's  the  liver,  as  an  Irish  friend  of  mine,  that  I  suspect 
one  may  say  it  as  a  joke.     Dr  Clouston,  who  paints  his  face,  keeps  me  here  as  a  profit 

to  the  concern.     Now  this  girl .     If  in  a  fortnight  Clouston  doesn't  let  me  up 

to  Craighouse  that's  the  superior  house  where  we  gets  tarts,  but  there  is  a  very  black 
hole  of  a  boot-house  yet,  would  you  as  an  S.S.C.,  is  it,  or  no,  a  writer  take  up  my 
case  as  a  sane  man,  for  the  girl's  sane  you  know.  I  have  enough  to  pay  you  some 
£1600  I  think  and  over,  and  I'll  spend  it  all  for  the  sake  of  the  honor  of  the  sex. 

The  Christians  here  all  love  one  another,  though  we  fight  at  times  like  the  Kilkenny 
cats,  but  try  afterwards  and  bury  one  another's  remains  for  the  sake  of  the  health  of 
the  remainder.     There  are  a  few  dear  little  children  here,  pigs,  and  rabbits. 

I'll  let  you  hear  in  a  fortnight,  if  the  powers  will  let  the  epistles  pass. 

You  never  sent  me  marriage  cards, — Your  afi".  friend. 

P.,S\— How's  the  little  boy'^? 

Acute  Mania. — The  "  raving  madness  "  of  the  older  authors,  or  acute 
mania,  ia  perhaps  the  type  of  all  insanity,  both  in  the  popular  and 
professional  mind.  Standing  thus,  and  being  the  least  rational,  least 
conscious,  most  noisy,  most  unmanageable,  and  sometimes  the  most  dan- 
gerous variety  of  mental  disease,  it  affected  the  conceptions  and  the  treat- 
ment of  all  other  varieties  in  a  most  unfavorable  way.  In  it,  many 
patients  had  no  more  "  reasoning  power  than  a  wild  beast,"  and  all  per- 
sons concluded  to  be  insane  (the  conception  of  insanity  was  then  a  much 
narrower  one,  embracing  much  fewer  persons),  were  accordingly  treated 
by  manacles  and  chains,  stripes  and  darkness.  Small  compassion  was 
felt  for  them,  few  laws  protected  them,  little  medical  skill  or  study  was 
exercised  in  their  behalf,  for  they  were  reckoned  beyond  the  pale  of  or- 
dinary humanity.  Even  in  Esquirol's  time,  at  the  beginning  of  this 
century,  such  patients  are  pictured  in  wild  contortion  and  fury  of  look  and 
action,  and  are  represented  heavily  bound  even  in  his  illustrations.  Yet, 
this  is  a  type  of  disease  that  is  now-a-days  not  at  all  so  common  as  others. 
Out  of  the  twenty-three  hundred  and  seventy-seven  admissions  into  the 
Royal  Edinburgh  Asylum  during  the  seven  years  1874-80,  only  two 
hundred  and  ninety-seven,  or  only  eight  per  cent.,  were  classified  as  acute 
mania,  and  there  were  not  twenty  of  these  that  could  have  sat  for 
Esquirol's  pictures.  Acute  mania  may  be  defined  as  intense  mental 
exaltation  with  great  excitement,  complete  loss  of  self-control,  with  some- 
times absolute  incoherence  of  speech  and  loss  of  consciousness  and 
memory.  After  twelve  months  it  is  arbitrarily  no  longer  reckoned  acute 
but  chronic  mania.     Some  authors  set  up  a  period  of  forty  days,  during 


STATES    OF    MENTAL    EXALTATION.  137 

which  alone  the  disease  was  to  be  called  acute  mania.  This  had  no 
foundation  in  any  clinical  fact. 

Acute  mania  begins  in  various  ways.  The  most  common  is  by  its 
commencing  as  simple  mania,  and  then  passing  into  the  acute  form.  But 
I  have  seen  it  begin  quite  suddenly,  the  patient  being  one  hour  a  sane, 
rational,  responsible  being,  and  the  next  acutely  maniacal.  It  often  has  a 
melancholic  prelude.  It  sometimes  begins  by  the  patient's  expressing  a 
delusion  out  of  which,  as  it  were,  the  extravagances  seem  to  arise. 
Sometimes  it  begins  by  emotional,  sometimes  by  intellectual  exaltations 
and  perversions,  sometimes  by  both.  At  other  times,  it  begins  by  altera- 
tions of  habit,  appetite,  and  propensity.  It  commonly  has  premonitory 
symptoms,  bodily  and  mental,  such  as  headaches,  a  confused  feeling  in 
the  head,  a  mliscular  fidgetiness,  an  unrest  of  body  and  mind,  a  feeling 
that  something  is  going  wrong  or  dreadful  is  to  happen,  a  feeling  of  wild 
commotion  in  the  head  as  if  it  were  to  burst,  an  impulsive  desire  to  do 
something,  to  break  glass,  or  do  violence  to  those  within  reach.  There  are 
usually  disturbed  sleep  and  constant  dreaming,  usually  of  an  unpleasant 
kind.  I  have  known  the  temperature  rise  to  over  100°  before  even  the 
patient  could  be  said  to  be  in  any  way  maniacal.  All  those  symptoms  in 
a  typical  case  are  soon  replaced  by  great  restlessness  and  muscular  agita- 
tion ;  a  complete  change  of  emotional  state,  this  often  becoming  very 
joyous ;  a  rapid  and  uncontrolled  passing  of  the  ideas  through  the  mind ; 
vivid  kaleidoscopic  mental  pictures  of  the  past;  scraps  of  former  life  and 
experience  suggested  by  chance  associations;  a  tendency  to  constant 
talking  whether  any  one  is  present  or  not;  passing  from  one  thing  to 
another  and  soon  becoming  incoherence  of  speech.  The  manner  is 
utterly  changed,  being  usually  jolly  or  fierce.  There  may  be  ceaseless 
laughinoj,  or  scoldinor,  or  swearino;.  Conversations  are  held  in  loud  tones 
with  imaginary  people  whose  voices  are  sometimes  heard  or  their  forms 
seen.  Sometimes,  too,  there  are  hallucinations  or  perversions  of  smell 
and  touch.  The  common  sensibility  and  all  the  senses  may  be  hyperses- 
thetic  at  first,  but  soon  become  dulled.  Sometimes  there  is  a  rhythmic 
action  of  mental  and  muscular  centres  seen  evinced  by  rhyming  all  the 
ordinary  conversation,  or  by  regular  movements  of  the  limbs  and  body. 
Frequently  there  is  a  tendency  to  shut  the  eyes  so  as  to  exclude  the  real 
impressions  of  the  senses,  and  live  in  the  false  consciousness  created  by 
the  morbid  energizing  of  the  bram.  Conversations  with  old  friends  now 
dead  will  be  carried  on.  Scenes  of  childhood  and  years  gone  by  will  be 
vividly  realized.  The  temperature  is  over  99°,  the  pulse  quick  and 
sometimes  full,  and  the  skin  moist  at  this  stage,  the  tongue  getting  furred, 
the  appetite  usually  gone,  the  tastes  and  sense  of  decorum  and  decency 
perverted.  At  the  end  of  this  stage,  the  power  of  self-control  may  be 
utterly  lost,  though  by  rousing  him  the  patient  may  by  an  effort  pick 
himself  up  and  talk  and  behave  rationally  for  a  few  minutes.  The 
memory  may  at  this  stage  be  good,  and  the  patient  remember  afterwards 
what  happened  then. 

A  still  further  stage  is  when  the  patient  gets  more  actively  excited, 
shouts,  sings,  attacks  those  about  him,  mistakes  their  identity,  calling 
them  by  different  names,  thinks  they  are  "acting"  on  him,  rushes  about, 
and  would  sometimes  injure  himself  or  those  near  him.     The  tongue  gets 


138  STATES    OF    MENTAL    EXALTATION. 

more  and  more  foul  and  soon  dry,  with  sordes  on  the  teeth  and  lips ;  the 
appetite  is  not  only  gone,  but  there  is  a  strong  revulsion  against  food,  so 
that  forcible  feeding  has  to  be  resorted  to.  The  speech  becomes  absolutely 
incoherent,  and  there  is  no  consciousness,  memory,  power  of  attention,  or 
any  care  for  the  calls  of  nature.  This  is  the  "delirious  mania"  of  some 
authors. 

The  degree  to  which  there  is  remembrance  afterwards  of  the  events 
occurring  during  acute  mania  differs  greatly  in  different  cases.  The 
friends  of  patients  will  usually  be  most  anxious  on  this  point,  fearing  the 
effect,  when  recovery  has  taken  place,  of  the  recollection  of  being  taken 
to  the  asylum,  of  being  fed,  etc.  I  advise  you  to  be  careful  in  predicting 
on  this  point.  In  some  cases  the  whole  period  of  the  disease  is  a  com- 
plete blank  afterwards ;  in  others,  things  heard,  seen,  and  experienced, 
during  almost  the  delirious  period,  are  remembered  afterwards  in  a  sort 
of  distorted,  exaggerated  way.  Patients  often  remember  and  complain  of 
the  restraint  and  the  force  needed  to  overcome  their  violence,  the  com- 
pulsory walking,  dressing,  and  feeding,  but  have  no  recollection  of  their 
own  condition  at  the  time  which  made  all  these  things  necessary.  I  think 
that  the  memory  of  events  during  the  disease  is  regulated  by  the  degree 
in  which  the  power  of  attention  is  unaffected.  In  health  you  know  how 
much  memory  depends  on  attention,  Avhich,  like  a  muscular  act,  implies 
much  fatigue  in  its  prolonged  exercise.  There  may  be  a  presentation  of 
an  object  to  the  eye,  or  a  sound  to  the  ear,  yet  if  there  is  no  attention 
there  is  no  brain  registration,  and  no  after-power  of  repi'esentation  or 
conscious  memory.  The  late  Professor  Laycock's*  views  in  regard  to 
memory,  organic  or  inherited,  in  regard  to  synesis  or  the  registration  of  an 
impression,  in  regard  to  the  recollection,  or  the  act  of  calling  up  the 
impression  to  consciousness  afterwards,  are  very  important  in  our  study 
of  the  clinical  symptoms  of  mania.  The  ravings  of  a  maniacal  patient 
are  often  well  worthy  of  study,  both  as  a  medico-psychological  problem, 
as  affording  an  insight  into  the  man's  mental  history  and  constitution,  and 
as  a  symptom  of  much  practical  import  to  the  physician.  There  is  no 
such  thing  as  real  "incoherence."  The  words  and  the  ideas  always 
cohere  by  some  bond  or  other.  They  always  relate  to  former  perceptions, 
thoughts,  and  experiences,  that  have  been  registered  in  the  brain  tissue. 
Those  are  represented  to  the  altered  consciousness  in  quick  succession  by 
chance,  not  real  association. 

A  careful  study  will  often  succeed  in  discovering  the  association  of  even 
the  most  apparently  incoherent  ideas.  The  ideas  have  had  some  former 
connection  in  the  consciousness  of  the  patient.  They  come  with  great 
vividness,  so  that  memories — representations — are  taken  for  actual  pre- 
sentations to  the  senses.  I  had  a  maniacal  patient  Avho  had  kept  dogs, 
and  their  mental  images  were  evidently  as  strong  as  the  real  sight  of  the 
animals  before  his  eyes  had  ever  been.  He  called  them  by  their  names, 
pointing  to  where  they  stood,  talked  to  them,  and  heard  them  barking. 
His  reasoning  power  being  perverted,  he  could  not  correct  those  impressions, 
and  he  believed  the  cerebral  images  of  his  former  presentations  to  be 

^  Journal  of  Mental  Science,  August,  1875 — "  Some  Organic  Laws  of  Personal  and 
Ancestral  Memory." 


STATES    OF    MENTAL    EXALTATION.  139 

present  realities.  We  may  either  suppose  that,  through  morbid  activity  in 
the  nutrition  and  energizing  of  the  centres  of  sensation,  those  molecular 
changes  which  each  previous  perception  had  left  are  rendered  more  vivid 
and  more  like  the  original,  as  Avhen  a  photograph  by  the  stereoscope  is 
made  to  look  real  and  solid;  or  that  through  failure  in  the  comparing  and 
judging  power  of  the  brain,  those  faint  images,  which  Ave  in  health  call 
memories,  are  actually  mistaken  for  real  perceptions  of  real  impressions 
on  the  senses,  just  as  when  in  a  dim  light  and  dreamy  humor  the  pictures 
on  the  wall  stand  out  as  real  men  and  women.  In  insanity  those  false 
beliefs  in  sense  impressions  are  called  hallucinations,  to  distinguish  them 
from  insane  delusions,  which  are  false  beliefs  of  a  more  abstract  kind.  If 
a  man  of  fifty  believes  that  he  fought  at  Trafalgar,  it  is  a  delusion  ;  if  he 
believes  that  he  sees  before  him  Nelson  lookino-  through  his  glass,  that  is 
a  hallucination.  There  is  a  false  belief  of  an  intermediate  kind,  to  which 
the  term  illusion  has  been  applied  by  some  authors,  but  this  term  will 
have  to  be  given  up  in  this  sense  now  that  Mr.  Sully  has  written  his 
book  on  Illusions  used  in  a  diiferent  meaning.^  In  the  sense  I  refer  to, 
if  the  person  really  saw  a  man  before  him  and  said  that  he  was  Nelson,  it 
would  have  been  an  illusion  ;  there  being  a  real  sense  impression,  but  this 
being  misinterpreted  into  something  quite  diiferent  from  Avhat  it  really  was. 
Certain  cases  of  acute  mania  are  greatly  characterized  by  the  prevalence 
of  hallucinations  of  different  senses.  All  those  symptoms  most  of  us  now 
believe  to  be  in  some  measure  explained  by  the  theory  of  the  morbid  exci- 
tation of  Ferrier's  and  Hitzig's  localized  centres  in  the  cortex  of  the 
brain,  those  centres  where  the  impressions  from  the  senses  are  received, 
and  where  coordinated  motions  arise.  As  further  progress  in  brain 
physiology  is  made,  no  doubt  we  shall  be  able  to  localize  in  the  brain  the 
causes  of  perverted  mentalization  of  different  kinds. 

As  illustrating  extreme  incoherence,  I  give  a  small  bit  of  a  "letter" 
of  twenty  pages,  containing  a  string  of  fourteen  thousand  words,  almost 
all  adjectives  and  nouns,  with  no  more  connection  or  aim  than  those  in 
this  specimen :  "  Mediterranean,  horses,  anathematized,  Athanasius,  propa- 
gated, emphatic,  monasteries,  diocese,  Egypt,  hermit,  biographer,  abuse, 
furor,  fury,  medium,  policies,  police,  hobby,  sacred,  phrase,  administration, 
ministerial,  monasticism,  .  .  .  counsel,  conviction,  revelation,  mode- 
rate, junior,  transact,  absurd,  disinherit,  repudiate,  maternal,  instinct, 
claimant,  reiterate,  clever,  rumor,  demurred,  finesse,  illusion,  abstruse." 
Now  you  see  that  there  is  a  sort  of  association  of  ideas  between  a  great 
number  of  these  words,  and  you  can  imagine  how  one  arising  before  the 
mental  vision  would  suggest  the  one  next  it.  Here  is  another  letter  from 
C.  K.,  of  a  more  usual  kind  of  half  incoherence :  "  Dear  Durham's 
Alia,  You  will  please  see  that  Eliza  and  Bella  are  out.  Mr  Swan  (his 
attendant)  is  to  give  you  this  in  a  few  minutes.  Compts.  to  Victoria 
and  my  mother  Queen  Elizabeth.  I  am  putting  '  John'  before  John 
Addison,  as  I  think  him  entitled  to  it.  No  kilts  my  bonnie  Durham. 
My  'charm  of  life.'  More  than  India's  goods  to  me.  Blessing  on  my 
bonnie  wife.     I  will  love  you  till  the  day  I  die.     Compts.  to  Louise 

'  Illusions,  by  James  Sully. 


140  STATES    OF    MENTAL    EXALTATIOX. 

and   darling   Beatrice,    Jane    Shore,    and   Elizabeth.      Come  into  the 
garden,  Maud. 

"  The  tear  fell  gently  from  lier  eye, 

When  last  we  parted  on  the  shore ; 
My  bosom  heaves  with  many  a  sigh, 

To  think  I  ne'er  should  see  her  more. 
'Weep  not,  my  love,'  I  trembling  said  ; 

'  Doubt  not  a  constant  heart  like  mine  ; 
I  ne"er  can  And  a  prettier  maid 

Whose  charms  can  fill  this  heart  of  mine.' 
*Go,  then,'  she  said,  '  and  let  my  constant  mind 

Oft  think  of  her  you  leave  in  tears  behind.' 
'Dear  maid,  my  heart's  embrace,  my  wish  shall  be. 

The  anchor's  weighed!     The  anchor's  weighed  ! 

Kemember  me.'  " 

There  is  no  diflSculty  in  seeing  the  association  of  ideas,  or  the  verbal 
or  alliterative  suggestions  running  through  this  "incoherence."  A 
rhyming  speech,  or  a  poetical  way  of  putting  things,  so  very  common, 
can  be  seen  in  the  above  letter. 

The  affective  condition  in  this,  as  in  every  variety  of  mania,  is  one 
of  perversion  or  paralysis.  We  would  describe  the  condition  in  most 
instances  by  saying  that  those  dearest  to  a  man  are  most  disliked ;  those 
most  trusted  are  the  objects  of  suspicion ;  those  most  intimately  asso- 
ciated with  the  patient  are  most  shunned.  It  is  this  which,  more  than 
anything  else,  makes  its  occurrence  such  a  terrible  calamity.  Conjugal 
affection  is  most  and  first  apt  to  give  way ;  and  it  is  a  very  common  fact 
that  where  we  have  prolonged  and  incurable  insanity,  the  conjugal  affec- 
tion of  the  sane  husband  or  wife  in  most  instances  ceases  long  before 
the  maternal  or  sisterly  affection  of  the  sane  blood-relations.  A  shrewd 
old  Morningside  head  attendant,  of  an  observant,  if  somewhat  cynical, 
turn  of  mind,  was  the  first  to  point  this  out  to  me  in  regard  to  those 
who  came  to  visit  the  chronic  patients  in  the  asylum.  He  said  he 
noticed  that  wives  and  husbands  were  the  first  to  diminish  the  frequency 
of  their  visits,  and  soon  came  very  seldom,  then  brothers  and  sisters, 
then  fathers,  and,  last  of  all,  mothers  and  old  aunts,  who  never  ceased 
to  come,  however  uninteresting  the  patient  might  be,  however  long  he 
was  insane.  No  rebuffs  from  the  patient  would  discourage  them ;  no 
want  of  reciprocity  would  cool  their  love  and  interest,  which  never  failed. 
I  commend  this  observation  to  students  of  the  affections. 

The  actions  of  patients  laboring  under  acute  mania  differ  as  much 
as  their  speech.  They  can  all  be  referred  to  the  morbid  excitation  of 
the  motor  and  the  ideo-motor  centres  in  the  brain.  One  man  is  simply 
restless,  another  shouts,  another  sings,  another  rushes  about  wildly, 
another  attacks  those  near  him,  this  being  usually  the  result  of  delusions 
that  they  are  going  to  injure  him.  Some  violence  on  slight  or  merely 
imaginary  provocation  towards  those  nearest  and  dearest  to  them  is 
common.  In  Plate  II.  (the  fac-simile  of  a  patient's  letter),  there  are  seen 
incoherence,  rapid  change  of  ideas,  and  hallucinations  of  sight.  Some- 
times the  patient  would  injure  himself  in  his  wild  fury  by  dashing  him- 
self against  walls,  through  windows,  etc.  But  it  is  surprising  how 
much  more  rarely  than  is  usually  supposed  maniacal  patients  are  really 


PLATE     II. 


^  J-^r^  -  ^^^^i^^.y^tJtjKU'C^^ 


OT^J 


^  H, 


/ 


>-i</4. 


STATES    OF    MENTAL    EXALTATION.  141 

or  to  any  extent  very  dangerous,  either  to  themselves  or  others.  In 
this  matter,  okl  opinions  and  prejudices,  the  fact  that  a  few  patients 
are  dangerous,  or  that  a  dangerous  stage  occurs  in  some  few  cases,  have 
given  a  wrong  general  impression,  and  done  very  much  harm  in  the 
treatment  of  acute  mania.  But  we  are  sloAvly  getting  over  this,  for 
now  we  endeavor  to  assume  that  any  patient  laboring  under  this  disease 
is  not  dangerous  till  he  is  proved  to  be  so,  instead  of  the  opposite  old 
maxim,  that  he  was  to  be  regarded  as  dangerous  till  he  proved  himself 
to  be  safe,  which  had  this  unfortunate  result,  that  the  restraints  and 
restrictions  and  supposed  safeguards  imposed  on  him  so  irritated  him 
that,  if  he  was  not  dangerous  at  first,  he  was  probably  made  so  by 
them.  No  safe  outlet  Avas  provided  for  his  morbid  motor  energy,  so 
that,  like  all  pent-up  force  finding  no  outlet,  it  became  dangerous,  and 
often  killed  the  patients. 

The  motions  and  gesticulations  of  an  acutely  maniacal  patient  are 
often  in  an  exact  degree  the  muscular  equivalents  of  the  ideas  and  emo- 
tions passing  through  his  brain,  just  as  they  are  in  the  case  of  a  savage 
or  a  born  orator  when  he  makes  a  speech  about  a  subject  which  excites 
him.  The  most  awkward  of  men  often  becomes  easy  in  his  motions 
when  maniacal.  The  expression  of  the  face  is  always  changed,  and 
also  the  appearance  and  expression  of  the  eyes.  Usually  the  man  is  so 
changed  that  he  looks  a  different  man.  He  is  ahvays  "worn-looking," 
and  this  is  more  particularly  the  case  in  the  female  sex.  There  is  no 
natural  beauty  of  face  that  will  continue  during  acute  mania.  Usually 
the  face  is  flushed;  the  skin  muddy  and  less  delicate  in  tint  and  texture; 
the  features  unpleasant  to  look  on.  As  might  be  expected,  the  infinitely 
delicate  coordinations  and  fixations  of  the  small  muscular  strands,  that 
in  the  face  mirror  forth  and  express  the  mental  and  emotional  states,  are, 
in  this  disease,  inharmonious,  and  express  instead  the  incoordinated 
mental  acts.  The  eyes  are  more  especially  characteristic.  They  usually 
glisten  somewhat,  as  in  fever;  the  eyelids  are  more  widely  dilated,  so 
that  the  white  is  seen  round  the  cornea;  and  their  expression  is  that  of 
excitement  and  turmoil. 

The  whole  digestive  tract  is  affected  more  or  less.  The  secretions  of 
the  mouth  and  the  saliva  are  altered  in  character,  and,  when  inoculated, 
produce  a  septic  or  irritating  influence.  The  sores  resulting  from  a  bite 
of  such  a  patient,  as  I  have  often  seen  in  attendants,  are  apt  to  be  angry, 
the  inflammation  running  up  the  lymphatics.  The  most  recent  investi- 
gations show  the  septic  character  of  the  saliva.  The  tongue  is  usually 
furred,  and  the  breath  foul.  When  the  condition  becomes  delirious, 
there  is  always  a  tendency  to  have  a  dry  mouth  and  tongue,  with  sordes 
on  the  teeth.  The  appetite  for  food  is  usually  paralyzed,  though  not 
always  that  for  drink.  The  digestion  is  often  vigorous  enough,  though 
not  in  the  exhausted  stage.  I  have  found  the  stomach  full  of  undigested 
food  in  patients  who  had  died  of  exhaustion  from  acute  mania.  The 
bowels  tend  to  be  costive,  though  this  is  not  always  so.  The  tempera- 
ture is  usually  from  one  to  two  degrees  above  the  normal,  especially  the 
evening  temperature.  As  we  shall  see,  it  runs  far  above  this  sometimes; 
but  if  it  rise  much  above  100°,  we  look  out  for  a  febrile  or  inflammatory 
cause,  or  for  general  paralysis,  or  for  organic  disease.      The  skin  is 


142  STATES    OF    MENTAL    EXALTATION. 

usually  clammy  and  ill-smelling,  though  sometimes  harsh  and  dry.  In 
women,  the  menstrual  function  is  almost  always  interfered  with,  being 
usually  stopped  after  the  excitement  has  continued  for  a  few  weeks. 
The  odor  from  a  woman  both  menstruating  and  maniacal  is  most  offen- 
sive. I  find  that  out  of  the  last  fifty  women  admitted  to  the  Asylum 
laboring  under  acute  mania,  three-fourths  had  irregular  menstruation, 
and  in  most  it  ceased  till  they  became  convalescent  or  demented.  The 
common  sensibility  is  much  diminished  in  such  cases,  patients  not  feeling 
pain  acutely,  some  not  feeling  it  at  all.  Injuries,  cuts,  boils,  whitlows, 
and  such  painful  affections  are  borne  without  any  complaint  of  pain. 
With  their  feet  inflamed,  they  will  walk — with  their  hands  in  sores,  they 
will  use  them  freely. 

The  continuance  of  this  condition  is,  of  course,  attended  Avith  rapid 
and  great  loss  of  body  weight.  I  have  known  a  patient  lose  a  stone  of 
flesh  in  a  week,  notwithstanding  that  he  was  getting  plenty  of  food. 
But  after  losing  any  redundancy  of  fiict,  it  commonly  happens  that  the 
intensity  of  the  disease  diminishes,  and  the  loss  of  weight  is  less  rapid. 
It  usually  takes  a  considerable  time,  always  provided  a  sufficient  quan- 
tity of  proper  food  is  given,  and  proper  treatment  adopted,  before  ex- 
treme emaciation  and  weakness  result.  The  more  intense  the  attack,  the 
shorter  is  usually  its  duration;  in  fact,  a  great  prolongation  of  very 
acute  delirious  mania  with  a  temperature  of  100°,  no  sleep,  and  con- 
stant violent  motor  excitement  are  inconsistent  with  life.  Few  cases  die 
in  the  first  week  of  the  attack;  some  do  in  the  first  fortnight,  and  some 
in  the  first  month.  In  a  somewhat  subacute  form,  it  is  wonderful  hoAV 
long  it  may  last,  without  producing  fatal  results,  or  even  reducing  the 
patient  very  much,  if  he  eats  enough — and  enough  may  mean  four  times 
his  usual  amount  of  food — and  is  sufficiently  in  the  fresh  air,  and  is  not 
restrained  in  his  movements.  In  by  far  the  majority  of  instances,  such 
mechanical  restraint  as  used  to  be  employed  in  this  country,  and  is  still 
employed  elsewhere,  by  strait-jackets,  gloves,  straps,  etc.,  causes  such  a 
feeling  of  degradation,  irritation,  and  resistiveness,  that  the  good  effect  of 
any  actual  conservation  of  force  by  restraint  is  in  my  opinion  far  more 
than  counterbalanced.  The  disease,  if  it  does  not  kill,  is  more  apt  to 
run  on  into  chronic  mania  and  dementia.  To  restrain  the  mere  outward 
muscular  movements,  while  the  motor  energy  is  all  the  while  being 
generated  in  the  brain  convolutions,  is  eminently  unphysiological.  Almost 
as  well  restrain  the  movements  of  the  choreic  or  the  convulsions  of  the 
tetanic  patient  by  binding  them  tightly,  and  expect  a  good  result.  Our 
great  efforts  in  the  treatment  of  such  cases  now  are  to  find  suitable 
outlets  for  the  morbid  motor  energy,  to  turn  the  restless,  purposeless 
movements  into  natural  channels,  to  get  the  patients  to  dig,  and  Avheel 
barrows  soon,  and  to  walk  long  distances,  instead  of  shouting  and  ges- 
ticulating. We  find  that  this  saps  and  exhausts  the  morbid  energy  and 
excitement,  producing  healthy  exhaustion  and  sound  sleep,  vigorous 
digestion,  and  healthy  excitation  of  the  skin,  the  glands,  and  the  excre- 
tory apparatus  generally.  This  is  the  chief  physiology  and  philosophy 
of  the  modern  British  non-restraint  treatment  of  mental  diseases.  No 
doubt  there  are  exceptions  to  all  rules.  I  have  seen  cases  where  re- 
straint had  to  be  applied  to  prevent  the  patient  exhausting  or  hurting 


STATES    OF    MENTAL    EXALTATION.  143 

himself,  but  tliey  are  amazingly  few  in  a  well-equipped  asylum,  with 
large  grounds,  a  firm,  good  attendants,  and  plenty  of  them,  and  a 
padded  room.  Under  those  circumstances,  not  one  case  in  ten  thou- 
sand is  found  to  need  restraint.  But  it  is  quite  diflFerent  Avhen  we 
have  to  treat  a  patient  in  a  private  house,  or  with  insufficient  attend- 
ance. Then  mechanical  restraint  may  be  quite  unavoidable.  It  often 
happens  that,  at  the  commencement  of  a  case,  where  the  symptoms  have 
developed  rapidly  into  an  acute  form,  you  may  think  it  advisable  to  give 
the  patient  a  chance  of  its  soon  passing  oif,  or  arrangements  cannot  be 
at  once  made  for  removal  to  an  asylum  through  the  absence  of  those 
who  can  authorize  it,  or  the  relations  of  the  patient  may  absolutely  insist 
on  his  being  treated  out  of  an  asylum.  In  all  these  circumstances,  you 
have  to  do  the  best  you  can  Avith  the  means  at  your  disposal,  carrying 
out  to  as  great  an  extent  as  you  can  the  principle  of  providing  an  outlet 
in  the  open  air  for  the  morbid  motor  energy  that  is  being  generated  in 
the  brain  convolutions,  but  using,  it  may  be,  restraint  to  some  extent. 

Acute  mania  may  in  most  cases  be  divided  into  three  stages :  the  first 
that  Avhich  I  have  described  as  simple  mania;  the  second,  that  of  ordi- 
nary acute  mania ;  and  the  third,  that  of  delirious  mania,  Avith  a  ten- 
dency to  dry  tongue,  etc.  The  third,  under  proper  treatment  of  the 
first  two  stages,  does  not  occur  in  many  of  the  patients. 

As  you  can  readily  understand,  from  the  delicate  constitution  of  the 
gray  brain- substance — that  highest  evolution  in  nature  of  combined  func- 
tion and  structure — and  the  infinite  complexity  of  its  balanced  and 
interdependent  functions,  the  continuance  of  such  an  abnormal  storm  as 
that  Avhich  exists  in  acute  mania  is  very  apt  to  be  folloAved  by  permanent 
and  irretrievable  damage.  Such  a  storm,  besides  all  the  bodily  symp- 
toms and  disturbances  Avhich  I  have  described,  is  accompanied  by  intense 
congestion  and  over-action  in  the  gray  neurine  and  brain  generally — the 
former  usually  seen  in  limited  areas  (see  Plate  III.),  Avhich  tends  soon 
to  pass  into  structural  changes.  The  cells  soon  get  granular;  there  is  a 
proliferation  of  the  nuclei  of  the  neuroglia;  the  lymphatic  spaces  and 
perivascular  canals  soon  get  over-dilated  and  blocked  up  Avith  debris,  and 
an  enormous  number  of  microscopic  capillary  extravasations  take  place 
in  and  around  the  convolutions  in  bad  cases.  Even  the  coverings  of  the 
brain  are  affected,  the  vessels  getting  thickened  in  their  coats  and  tor- 
tuous, the  fibrous  matter  of  the  pia  mater  getting  hypertrophied,  the 
arachnoid  milky,  the  dura  mater  thickened  or  adherent  to  the  bone,  and 
even  the  bony  case  becoming  dense  and  thickened. 

All  those  things  happen  through  prolongation  of  the  acute  symptoms. 
Therefore,  it  is  of  the  last  importance  to  shorten,  if  we  can,  the  acute 
stage.  Every  Aveek  of  this  adds  to  the  chances  of  the  acutely  excited 
state  being  folloAved  by  more  or  less  permanent  mental  defect.  Even  the 
present  risk  to  life  is  not  so  grave  a  risk  as  that;  for  which  of  us,  if  we 
had  the  choice,  Avould  not  prefer,  on  the  whole,  death  to  a  degradation 
from  our  mental  and  emotional  eminence  in  creation  to  a  state  of  per- 
manent mindlessness,  in  Avhich  Ave  would  be  dead  to  the  love  and  hatred 
and  to  the  joys  and  pains  of  life,  oblivious  of  the  past,  and  unconcerned 
for  the  future;  stirred  by  no  ambition;  capable  of  no  effort,  and  un- 
moved by  any  motive  ?     For  such  is  dementia,  of  which  I  am  to  speak 


144  STATES    OF    MENTAL    EXALTATION. 

afterwards,  that  follows  and  results  from  mania.  About  sixty  per  cent, 
of  the  cases  of  acute  mania  recover,  seven  and  a  half  per  cent,  die,  and 
thirty-two  and  a  half  per  cent,  become  demented,  or  pass  into  chronic 
mania.  There  is,  perhaps,  more  opportunity  for  right  treatment  and 
management  in  acute  mania  than  in  any  other  kind  of  mental  disease. 

General  Indications  for  the  Treatment  of  Acute  Mania. — In 
the  beginning  of  the  attack,  and  sometimes,  when  the  patient  is  wealthy, 
all  through  it,  Ave  have  to  treat  the  case  at  home.  Now,  no  doubt,  the  first 
thing  to  be  done  is  to  get  properly  trained  attendants — one,  two,  three, 
or  even  four  may  be  necessary  for  night  and  day  work.  Patient,  sen- 
sible, experienced,  cool  and  kindly  men  or  women  are  what  we  want. 
Then  proper  arrangements  must  be  made,  a  good  suite  of  two  large 
rooms  on  the  ground  floor  of  a  house,  with  a  garden,  and  not  too  near  a 
public  road,  being  required.  Small  breakable  articles  must  be  removed, 
but  do  not  make  the  rooms  quite  desolate  or  unattractive  looking.  Fasten 
windows  not  to  open  more  than  five  or  six  inches,  and  see  that  no  knives 
or  lethal  Aveapons  are  too  handy.  But  do  not  do  all  this  demonstratively 
to  attract  the  patient's  attention.  Next,  you  must  look  to  the  feeding 
with  suitable  nutriment  very  often ;  sometimes  you  can  give  it  only  little 
and  often;  sometimes  in  ordinary  meals,  with  beef-tea  and  milk  in 
between.  Milk,  eggs,  beef-tea,  ground  beef,  custards,  strong  soups,  with 
plenty  of  vegetables,  and  porridge  are  the  best,  as  often  as  the  patient 
can  be  got  to  take  them,  and  in  as  large  quantity.  Do  not  for  a  moment 
be  afraid  of  a  dirty  tongue,  and  think  it  contraindicates  food.  Nothing 
could  be  a  greater  mistake,  in  acute  mania  at  all  events.  The  furred 
tongue  is  not  from  an  overloaded  alimentary  canal,  but  results  from  per- 
verted innervation  of  the  digestive  tract.  Malt  liquors,  such  as  porter 
and  ale,  can  be  given  freely  Avith  advantage — good  wines,  too,  if  they 
can  be  got.  Even  whiskey  or  brandy  Avill  act  as  a  direct  sedative  to  the 
excitement  in  some  cases.  Anstie  taught  us  some  good  therapeutics,  in 
his  Stimulants  and  Narcotics,  on  this  point.  But  alcohol,  you  will 
find,  Avill  sometimes  flush  and  cause  excitement.  In  that  case,  use  it 
sparingly.  I  haA^e  seen  a  pint  of  beef-tea  representing  all  that  was 
soluble  in  a  pound  of  beef-steak  and  a  glass  of  Avhiskey  reduce  the  tem- 
perature 2-3°.  To  show  the  quantity  of  food  that  such  patients  can 
take  and  digest,  I  mention  that  at  the  asylum  I  am  never  satisfied  except 
the  bad  cases  get  at  least  six  eggs  a  day  beaten  up  in  liquid  custards,  in 
addition  to  their  ordinary  food,  beef-tea,  etc.  I  have  known  many  pa- 
tients take  a  dozen  eggs  a  day  for  three  months  running.  The  constant 
motion  and  fresh  air  enable  them  to  digest  and  assimilate  all  this.  So 
long  as  a  patient  is  losing  Aveight,  the  physician  should  never  be  satis- 
fied. When  he  becomes  stationary,  then  one  may  begin  to  think  that 
the  disease  is  being  overcome  by  nature  and  treatment.  "When  he  begins 
to  gain  in  weight,  and  the  temperature  becomes  normal,  then  con- 
valescence or  dementia  has  begun.  The  patient  should  be  weighed  every 
week  during  the  acute  stage. 

Next  to  good  food  and  nursing,  fresh  air  is  most  essential  in  treating 
a  case.  No  patient  must,  on  any  account,  or  in  any  Aveather,  except  he 
is  excessively  run  doAvn  indeed,  be  kept  in  bed  or  in  the  house.  Herein 
is  the  essential  difference  between  the  treatment  of  this  disease  and  that 


STATES    OF    MENTAL    EXALTATION.  145 

of  acute  bodily  complaints.  I  often  keep  patients  out  all  day  in  the 
summer-time.  When  they  are  getting  better,  they  all  say  that  they 
feel  better  out  than  in.  There  is  no  soporific,  no  calmative,  and  no 
digestive  like  the  fresh  air.  And  the  attendants  must  not  restrain  or 
interfere  more  than  is  necessary.  There  should  be  no  nafjfrinfr  and 
small  interferences,  and  no  arguing,  but  a  kindlv,  firm  mode  of  dealing 
with  a  patient — coaxing,  when  coaxing  will  do,  and  firm  insistance  and 
force  sufficient  to  overcome  resistance  Avhen  necessary.  There  is  a  certain 
kind  of  tact  which  some  people  have,  and  which  may  be  partly  acquired, 
but  which  is  often  a  natural  gift,  and,  when  present,  is  of  the  greatest 
avail  in  overcoming  resistance,  persuading  patients  to  take  food,  etc. 
Women  have  it  more  frequently  than  men,  and  women  will  often 
persuade  male  patients  Avhen  their  own  sex  fails.  It  does  not  do  to  let 
patients  have  too  much  of  their  own  way.  A  happy  mean  between  that 
and  too  much  interference  should  be  pursued.  It  is  better  to  be  honest, 
and  not  deceive  patients  into  doing  things.  That  often  makes  them  lose 
confidence,  and  does  harm  after^Yards.  Medicine  when  given  should,  as  a 
general  rule,  be  given  as  medicine,  and  not  be  put  in  food  surreptitiously. 
The  safety  of  the  patient  and  those  about  him  must  of  course  be  pro- 
vided for. 

For  the  bowels  it  is  sometimes  necessary  at  first  to  use  laxatives  and 
enemata,  and  even  strong  purgatives,  such  as  croton  oil,  but  I  try  first 
such  mild  medicines  as  castor  oil,  Tamar  Indien  lozenge,  liquorice  powder, 
warm  water  enemata,  etc.  Do  not  insist  on  a  stool  every  day ;  one  every 
second  or  third  day  is  quite  enough.  Depleting  remedies  of  all  sorts  are 
in  my  opinion  bad. 

There  is  one  remedy  that  I  have  seen  do  good  in  many  cases,  and  in  a 
few  act  like  a  charm,  and  that  is,  prolonged  warm  baths  with  cold  to  the 
head.  The  effect  of  this  is  to  fill  the  capillaries  all  through  the  body, 
and  to  withdraw  blood  from  the  brain,  to  depress  the  heart's  action, — and 
hence  its  danger, — to  soothe  the  nervous  irritation,  and  to  produce  sleep. 
I  have  the  highest  opinion  of  its  efficacy,  but  unfoi-tunately  it  is  attended 
with  danger  in  some  cases.  A  man,  whom  I  could  not  detect  to  have 
heart  disease,  once  died  in  my  hands,  as  it  were,  when  I  was  sitting 
beside  him,  after  being  less  than  an  hour  in  water  at  103°.  I  know  of 
two  other  cases  where  syncope  and  death  resulted  in  the  same  way.  I 
used  to  keep  the  water  up  to  110°,  but  I  never  do  so  now.  In  fact, 
I  now  prefer  99°  as  the  proper  temperature.  But  the  effect  with  this  is 
not  so  quick  or  so  marked.  Baillarger  used  to  keep  his  patients  steeping 
for  days  in  water  at  96°  or  98°.  I  do  not  think,  however,  the  treatment 
is  so  much  in  vogue  noAv  in  Paris  as  it  was  twenty  years  ago.  Shower- 
baths  of  a  mild  kind  are  sometimes  useful  when  the  mania  threatens  to 
become  chronic,  or  when  the  earlier  symptoms  of  dementia  show  them- 
selves, and  the  patient  is  strong  and  can  react  after  the  bath.  The  great 
trouble  is  that  patients  are  apt  to  look  on  the  shower-bath  in  any  form  as 
a  punishment,  and  so  its  use  may  have  a  bad  moral  effect  on  them. 

One  difficulty  in  treatment  is  to  use  narcotics  and  hypnotics  rightly. 
The  greatest  differences  of  opinion  have  existed,  and  do  prevail  at  present, 
about  them.  What  we  want  and  have  not  yet  got  is  a  medicine  that  will 
cause  really  natural,  restful,  refreshing  sleep.     Then  we  want  a  medicine 

10 


146  STATES    OF    MEXTAL    EXALTATION. 

that  will  stay  or  slacken  the  morbid  energizing  of  the  brain  cells  in  the 
convolutions  without  aiFecting  the  appetite  or  the  nutrition.  That,  how- 
ever, is  not  known  to  us  in  a  perfect  form.  All  medicines  that  tend  to 
lessen  the  appetite  or  impair  the  digestion  or  nutrition,  I  condemn 
utterly  in  this  disease.  In  ninety-nine  cases  out  of  a  hundred  opium 
does  this,  and  should  not  be  employed  except  as  a  mere  temporary 
placebo  or  for  a  special  purpose.  My  experiments  with  it,  and  practical 
experience  of  it  is,  that  it  has  those  objectionable  eflects  in  most  cases 
where  given. 

Chloral  we  all  believed  in,  and  used  most  extensively  in  mania  after 
its  discovery.  It  seemed  a  perfect  sleep-producer.  Numbers  of  cases 
have  I  kept  under  its  influence  day  and  night  for  weeks,  and  many  of 
them  certainly  got  well.  But  I  do  not  believe  so  much  in  it  now.  Its 
sleep  is  sound  and  seems  natural,  but  somehow  is  not  refreshing  like 
nature's  sleep.  I  am  inclined  to  think  that  one  or  two  hours'  sleep 
naturally  after  a  day's  exercise  in  the  open  air  is  more  than  equal  to  eight 
hours'  chloral  sleep.  My  experience  is  that  it  has  a  subtile  influence  for 
harm  on  the  brain  when  much  given,  by  which  the  organ  loses  that 
quality  which  we  call  tone.  The  patients  cannot  bear  pain  so  well. 
They  have  not  the  resistive  power,  and  they  are  apt  to  look  pale  and  unre- 
freshed  in  the  morning.  Besides  this,  I  had  two  patients  who  died 
suddenly,  each  of  them  during  a  sudden  gust  of  excitement  when  under 
the  influence  of  moderate  doses  of  thirty  grains  ;  in  both  of  them  I  found 
the  blood  dark  and  fluid,  and  the  right  side  of  the  heart  and  the  lungs 
engorged,  as  if  there  had  been  a  sudden  paralysis  of  the  breathing  centre 
in  the  pons.  I  could  not  certainly  say  that  the  chloral  caused  their 
death.  One  had  decided  brain  disease,  and  sudden  deaths  do  occur  in 
.acute  mania  when  no  medicine  has  been  given,  through,  as  I  believe,  epi- 
leptiform conditions  causing  paralysis  of  the  breathing  centre.  I  have 
never  given  so  much  chloral,  especially  as  a  sedative  during  the  day, 
since.  Now  I  give  it  at  night,  or  after,  or  during  convulsions,  and 
always  in  small  doses  of  from  ten  to  twenty-five  grains,  with  from  half  a 
•drachm  to  a  drachm  of  bromide  of  potassium. 

A  combination  that  I  have  found  most  useful  has  been  the  bromide  of 
potassium  and  tincture  of  cannabis  indica,  with  which  I  have  made 
careful  and  prolonged  experiments.  It  soothes  during  the  day,  and  some- 
times permanently  allays  the  brain  excitation,  and  it  causes  sleep  at 
night,  without  diminishing  the  appetite  much  or  impairing  the  digestion. 
I  have  used  the  bromide  alone  in  acute  mania  extensively  and  experi- 
ihentally.  In  small  doses  it  seems  to  have  no  effect.  In  very  large  and 
continuous  doses,  say  a  drachm  every  three  hours  continued  for  many 
days,  it  Avill  cause  bromism,  and  quiet  the  patient,  but  when  its  influence 
is  over  he  becomes  as  bad  as  ever.  I  have  never  seen  any  medicine, 
where  the  maniacal  excitement  and  the  physiological  brain-torpor  of  the 
drug  seemed  so  visibly  to  fight  for  the  mastery.  Hyoscyamine  is  an 
admirable  quieter  of  motor  restlessness,  and  often  does  no  harm,  but  I 
have  seen  dangerous  coma  produced  by  it,  and  its  subjective  effects  on  the 
patients  must  be  disagreeable,  for  they  dislike  it  extremely.  I  have  seen 
nitrite  of  amyl  (a  drop  inhaled)  produce  calm  in  a  suddenly  epileptiform 
f'nsp  of   mania.     Morphia   and   hyoscyamine   may   be   subcutaneously 


STATES    OF    MENTAL    EXALTATION.  147 

injected  if  refused  by  the  mouth,  but  I  advise  you  to  beware,  and  not 
use  too  large  doses  in  this  way.  It  may  be  justifiable  in  treating  cases  at 
home  to  tide  over  severe  paroxysms  with  those  drugs,  and  sometimes  to 
keep  the  patient  out  of  an  asylum  as  long  as  possible.  AVhen  a  maniacal 
patient  is  sent  to  the  asylum,  I  now  frequently  use  for  a  few  nights  small 
doses  of  the  bromides  and  chloral,  and  give  warm  baths  ;  but  after  a  fort- 
night, when  I  see  that  the  attack  is  not  going  to  be  cut  short  or  run  a 
very  short  course,  I  trust  to  the  nursing,  diet,  and  conditions  of  life  I 
have  mentioned,  with  continuous  tonics.  Conium  is  a  good  sedative  in 
some  cases,  and  tincture  of  lupuline,  in  the  milder  cases,  I  have  known 
to  produce  sleep.     Camphor  in  some  women  does  much  good. 

I  now  give  nearly  all  my  cases  quinine  from  the  beginning,  adding 
iron  in  some  cases  that  are  manifestly  anemic,  with  sometimes  the  phos- 
phates of  lime  and  soda.  The  bitter  tonic  and  digestive  medicines  I  use 
largely  in  cases  that  run  on  for  long,  and  during  convalescence. 
Strychnine  is  most  useful  at  the  stages  of  the  disease  Avliere  there  is 
a  tendency  to  stupor  and  brain-torpor. 

When  the  acute  symptoms  pass  off,  especially  if  they  have  lasted  long, 
there  is  apt  to  be  a  stage  of  reaction,  attended,  in  some  cases,  with  com- 
plete prostration,  in  others  with  depression,  in  others  with  an  apparent 
mental  enfeeblement  which  most  closely  resembles  dementia ;  in  fact,  it 
is  a  dementia  or  stupor  of  a  transitory  kind.  You  must  on  no  account 
confuse  it  with  the  real  dementia,  for  while  the  one  is  quite  amenable  to 
treatment,  and  requires  treatment  urgently,  the  other  is  an  incurable 
brain  condition.  I  once  myself  showed  a  girl,  who  had  just  passed 
through  a  prolonged  attack  of  acute  mania,  and  who  was  stupid,  dirty  in 
habits,  and  demented,  used  her  as  a  typical  example  of  newly  begun  de- 
mentia in  a  clinical  lecture,  and  pronounced  her  a  hopelessly  incurable 
case;  but  she  gradually  picked  up  in  flesh,  got  enormously  fat,  and  her 
brain  roused  itself  into  almost  its  former  activity,  and  she  was  discharged 
recovered.  The  treatment  for  this  stage  of  acute  mania  is  tonic  and 
nerve  stimulant,  stimulating  medically  and  fattening  dietetically  (use  beef 
and  animal  food  at  this  stage  as  much  as  possible).  Rousing  and  occu- 
pation, and  "  cheering  up  "  by  amusements,  etc.,  are  most  useful,  too,  as 
brain  stimulants  and  restorers.  Sometimes  patients  have  to  leave  the 
asylum  to  get  cured  of  this  sequela  of  mania.  Their  brains  need  to  be 
subjected  to  the  natural  stimuli  and  interests  of  outside  natural  life. 
There  is  a  process  of  reeducation  of  their  damaged  but  recuperating 
brains  that  must  be  gone  through.  They  are  in  the  state  of  a  joint  dam- 
aged by  an  acute  rheumatic  inflammation,  that  may  take  a  long  time  and 
much  care  and  treatment  to  get  it  working  as  it  once  did.  As  I  shall 
point  out,  certain  mental  peculiarities  remain  permanently  in  many 
cases. 

The  following  was  a  typical  case  of  acute  mania,  running  through  its 
three  stages  both  in  its  onset  and  as  it  passed  away.  The  intensity  of 
the  brain  exaltation  was  so  great  at  the  acme  as  almost  to  kill  the  pa- 
tient : 

C.  L.,  xt.  36.  Married.  Temperament  sanguine.  Diathesis  ner- 
vous. Disposition  cheerful,  frank,  and  exceedingly  enthusiastic  when  he 
took  anything  up.     Habits  very  steady,  and  almost  over-industrious,  for 


148  STATES    OF    MENTAL    EXALTATION. 

after  his  work  was  done  he  would  spend  all  his  evenings  in  doing  church 
work.  Education  fair.  Fatlier  died  at  seventy,  of  paralysis ;  brother 
had  an  attack  of  acute  mania  at  twenty  seven  from  over-brain-work,  from 
which  he  resovered,  and  then  again  had  another  attack,  and  died  in  it. 
Mother  had  an  attack  of  puerperal  mania  after  the  birth  of  one  of  her 
children,  and  her  maternal  grandfather  and  aunt  were  insane.  This  is 
the  first  attack,  and  has  assumed  an  acute  form  for  three  days.  He  be- 
came depressed,  reserved,  and  altered  three  or  four  weeks  ago,  and  this 
was  accompanied  by  thinness  and  sleeplessness.  Then  he  began  to  be 
excited,  elevated,  talkative,  and  restless,  and  quickly  passed  into  wild 
delirious  excitement,  which  had  existed  for  two  days  before  admission. 
He  was  most  dangerous  to  his  wife  and  children.  He  had  taken  little 
food  for  two  days,  and  never  slept  during  that  time,  though  he  seems  to 
have  had  enormous  doses  of  morphia. 

On  admission  he  was  very  exalted,  singing  hymns,  quoting  passages 
of  Scripture,  and  swearing  in  the  same  breath ;  shouting  and  raving. 
His  excitement  was  intense.  He  threw  himself  about  the  padded  room, 
into  which  we  had  to  put  him.  It  took  four  or  five  strong  men  to  man- 
age him  safely,  though  he  was  a  small  man.  He  had  hallucinations  of 
sight  and  hearing.  He  was  thin  and  sallow.  He  was  covered  with 
bruises,  and  one  rib  was  broken,  all  got  in  his  struggles  at  home.  His 
tongue  was  clean  and  dry,  bowels  costive,  appetite  gone.  Pulse  diflScult 
to  count,  on  account  of  his  excitement.  Temperature  99°  on  admission, 
and  100.6°  at  night.  He  felt  no  pain  ;  his  motions  were  incessant  and 
most  severe.  He  would  put  his  feet  up  on  the  walls,  with  his  head  down, 
and  run  so  round  the  room.  He  would  leap  up  and  fall  down.  He 
would  seize  those  near  to  him,  and  try  to  throttle  them,  thinking  they 
were  devils.  He  tore  his  blankets  and  bedding.  At  times  he  would  be 
quiet,  and  in  a  way  rational,  then  he  would  get  maniacal  in  a  moment 
without  warning  and  without  cause.  He  was  fed  regularly  with  custards 
and  sherry  by  force,  as  he  had  a  great  aversion  to  food,  saying  it  was 
poison.  Patients  who  are  maniacal,  often  have  this  delusion,  the  idea 
being  suggested  to  them  by  their  own  perversion  of  the  sense  of  taste. 
I  have  no  doubt  that  all  food  tastes  ill  to  them.  This  brain  condition 
exhausted  him  very  much,  so  that  I  feared  he  was  going  to  die.  Getting 
twelve  eggs  a  day  for  the  first  fortnight,  yet  he  made  little  progress. 
We  could  only  get  him  into  the  fresh  air  for  a  short  time  each  day,  his 
struggles,  and  the  risk  of  injuring  himself,  being  so  great.  His  tempera- 
ture at  this  time  was  about  99°  in  the  morning  and  100°  at  night,  and 
he  almost  never  slept.  Soon  he  began  to  improve,  and  his  lucid  inter- 
vals began  to  be  more  clear  and  frequent.  He  had  several  boils  on  his 
arms  and  legs  at  the  time,  and  I  looked  on  this  as  a  critical  event.  His 
temperature  never  rose  so  high  after  this,  his  appetite  returned,  and  we 
were  able  to  give  him  solid  food  in  a  mixed  form  for  the  first  time.  He 
was  able  to  walk  round  the  grounds  in  foui*  weeks,  being  then  talkative, 
lively,  chafiing  everybody  he  met,  full  of  fleeting  delusions,*  especially  as 
to  the  identity  of  those  near  him.  He  took  most  violent  antipathies  to 
his  attendants,  and  would  accuse  them  of  quite  impossible  cruelties  to 
him,  such  as  putting  him  into  a  mill  and  breaking  every  bone  in  his 
body,  so  that  we  had  to  be  constantly  changing  them  to  soothe  him.     He 


STATES    OF    MENTAL    EXALTATION,  149 

was  weak,  pale,  thin,  and  haggard,  but  said  he  felt  strong,  when  he  began 
to  go  out  to  walk.  After  that  he  was  never  in  the  house,  except  at  night. 
He  walked,  and  when  tired  he  sat  or  lay  down  on  seats  in  the  grounds. 
He  continued  excited,  noisy,  singing,  and  most  exalted  in  feeling,  from 
the  second  month  of  his  stay,  still  taking  his  twelve  eggs  a  day,  in  addi- 
tion to  his  ordinary  diet  and  other  extras,  and  he  gained  a  stone  the 
second  month  of  his  residence.  He  had  several  short  relapses  for  a  few 
days.  In  two  and  a  half  months  he  began  to  have  a  glimmering  con- 
sciousness of  his  position,  and  a  faint  return  of  natural  feeling.  His 
first  letter  to  his  wife  at  that  time  was  a  model  of  conciseness  :  "  Dear 
Wife,  Where  are  you  ?     C  L." 

In  three  months  he  was  in  the  condition  I  have  described  as  typical  in 
simple  mania — gay,  humorous,  careless,  talkative,  but  with  no  delusions, 
sleeping  well,  and  rapidly  gaining  in  weight  and  strength.  He  was  all 
this  time  getting  all  sorts  of  tonics,  quinine,  iron,  phosphates,  cod-liver 
oil,  etc.  This  state  lasted  over  three  months,  all  this  time  his  brain  get- 
ting more  normal  in  its  working,  and  at  the  end  of  six  months  from  his 
admission  he  was  discharo;ed  well  in  mind  and  stouter  than  he  had  ever 
been  in  his  life,  having  gained  two  stones  in  weight  since  admission.  I 
never  believe  in  the  perfection  of  a  recovery  from  acute  mania,  unless 
the  patient  is  fat ;  and  when  he  is  so,  I  always  think  his  chances  of  not 
having  a  relapse  for  some  time  are  good.  I  like  a  gradual  steady  recov- 
ery, too,  not  perhaps  so  long  as  this,  rather  better  on  the  Avhole  than  a 
sudden  recovery. 

The  following  is  another  characteristic  case  of  acute  mania  running 
through  a  typical  course: 

C.  N.,  let.  47,  of  a  sanguine  temperament,  cheerful  and  frank  disposi- 
tion, and  industrious  and  temperate  habits,  but  of  a  very  fiery  and  un- 
governable temper.  This  was  her  fii*st  attack.  Her  mother  was  insane. 
This  heredity  and  the  nearness  of  the  climacteric  period  may  be  consid- 
ered as  the  predisposing  causes,  while  the  exciting  cause  was  exhaustion 
from  want  of  sleep,  and  mental  anxiety  in  nursing  her  mother  on  her 
deathbed.  The  first  mental  symptoms  occurred  about  fourteen  days 
before  admission  in  the  shape  of  restlessness,  unsettledness,  and  getting 
up  in  the  middle  of  the  night  to  wash.  For  four  days  she  had  been 
worse,  seeing  visions,  constantly  talking,  imagining  that  people  were 
under  her  bed,  and  never  sleeping.  On  admission  there  were  great  exal- 
tation, incessant  and  almost  incoherent  talking,  much  excitement,  walking 
about,  gesticulation,  singing,  saying  she  saw  the  "heads  of  people" 
about  her.  She  addressed  the  people  about  her,  whom  she  had  never 
seen  before,  as  her  friends,  mistaking  their  identity,  making  sarcastical 
remarks  about  them — "  Oh !  Kitty,  is  that  you  ?  That's  a  fine  gown 
you  have  on.  Who  gave  you  it?  Is  it  paid  for?  "  etc.,  etc.  At  times 
she  was  quite  incoherent.  In  person  she  was  fat,  weighing  eleven  stone 
six  pounds.  Her  organs  were  healthy,  except  that  her  tongue  Avas  much 
furred,  and  her  bowels  were  costive.  Pulse  112;  temperature  99.6°. 
Soon  after  admission  she  suddenly,  in  obedience  to  a  delusion,  took  up  a 
chair  and  threw  it  at  one  attendant,  while  she  seized  another  by  the  hair 
and  hurt  her  considerabl3%  screaming  out  and  saying  they  were  going  to 
murder  her,  and  that  there  were  devils  in  the  room.     She  refused  to  take 


150  STATES    OF    MENTAL    EXALTATION, 

food  at  first,  saying  it  "was  poisoned.  She  had  to  be  secluded  in  a  bed- 
room, where  she  woukl  sometimes  shout  and  gesticuhite  and  make 
speeches,  and  carry  on  conversations  with  imaginary  persons;  then  she 
would  lie  flat  on  her  back  on  the  floor,  keeping  her  eyes  tightly  shut, 
smiling,  and  never  speaking  at  all  or  answering  questions,  evidently 
living  in  her  morbid  imaginations,  and  trying  to  exclude  external  sensa- 
tions. She  did  not  sleep,  and  was  noisy  all  night  till  the  third  night, 
when  she  slept  two  hours.  On  the  first  day  she  was  so  violent,  and  so 
strong,  and  so  resistive,  that  it  Avas  thought  desirable  not  to  dress  her  or 
send  her  out.  She  was  got  into  a  wann  bath  with  great  difficulty.  Her 
temperature  rose  to  100°.  It  was  the  fourth  day  before  she  began  to 
take  more  food  than  a  little  milk,  or  before  we  could  get  her  dressed  and 
out  in  the  open  air  much.  Her  bowels  had  been  costive  till  then,  as  she 
could  not  be  got  to  take  any  medicine.  She  then  had  croton  oil  given 
her  and  an  enema,  and  had  a  free  evacuation  of  most  offensive  feces. 
Her  breath  had  been  very  foul.  On  the  sixth  day,  though  she  was  drink- 
ing a  good  deal  of  milk  and  custards,  her  tongue  and  mouth  got  dry  and 
cracked,  her  pulse  weak,  and  she  showed  signs  of  exhaustion.  She  was 
put  on  four  glasses  of  wine,  and  still  kept  out  in  the  fresh  air,  while  a 
little  milk  was  given  her  every  half  hour.  She  was  very  excited,  noisy, 
destructive,  and  absolutely  delirious  and  incoherent.  On  the  tenth  day 
the  excitement  began  to  abate,  her  tongue  and  mouth  became  moist ;  she 
became  more  manageable,  and  got  a  good  night's  sleep  for  the  first  time. 
In  a  month  from  the  time  of  her  admission  she  had  lost  twenty-four 
pounds  in  weight,  but  then  the  acuteness  of  the  brain  exaltation  passed 
ofi".  She  had  ''a  good  day  and  a  bad  one,"  could  sit  down  to  meals,  and 
eat  her  food.  She  could  walk  about,  looking  moderately  sane  to  any  one 
at  a  little  distance.  She  could  answer  simple  questions  correctly.  She 
began  to  have  doubts  as  to  a  delusion  about  my  being  her  husband,  say- 
ing, in  answer  to  my  question  as  to  who  I  was — "You're  John ,  at 

least  you  look  like  him;  but  I'm  thinkin'  you're  no  him."  She  made  a 
perfect  recovery  in  four  months. 

The  following  is  a  case  of  acute  mania  coming  on  in  an  hour,  with 
great  intensity,  and  gradual,  but  not  complete  recovery  in  three  months. 
Relapse  after  three  and  a  half  years,  attack  of  ten  months'  duration, 
complete  recovery. 

C.  M.,  aet.  17.  Diathesis  nervous.  Disposition  excitable  and  sensi- 
tive. Comes  of  a  nervous  stock  ;  and  a  maternal  cousin  is  insane.  He 
had  been  in  low  spirits,  and  rather  more  sensitive  and  shrinking  than 
usual.  There  was  no  proof  of  masturbation,  though  I  supposed  that  his 
thoughts  had  been  erotic  from  various  small  indications.  Being  very 
strictly  brought  up,  all  the  outward  influences  had  been  in  favor  of  severe 
repression  of  the  nisus  generativus.  The  exciting  cause  was  said  to 
have  been  a  fright,  but  I  scarcely  think  there  was  suflBcient  proof  of  this. 
One  day  he  suddenly  began  to  roar  and  shout,  and  say  he  was  first 
Christ,  and  then  the  devil,  and  to  be  most  violent  to  those  about  him. 
He  got  so  ill  and  so  unmanageable  that  he  had  to  be  removed  to  the 
asylum  the  same  night  his  attack  began,  which  in  most  cases  would  be 
considered  a  premature  measure,  considering  the  public  feeling  existing 
about  hospitals  for  the  insane,  and  the  harm  a  residence  in  one  may  do 


STATES    OF    MENTAL    EXALTATION.  151 

to  a  man's  prospects,  hoAvever  much  it  may  be  true  that  the  best  treat- 
ment for  the  patient  couhl  be  got  there.  His  delusions  were  transient, 
most  of  them  beino;  of  a  religious  nature.  His  condition  was  that  of  a 
typically  acute  delirious  mania  when  let  alone ;  but  when  his  attention 
was  roused  by  questioning,  he  could  answer  some  simple  questions  co- 
herently, though  not  correctly,  his  memory  being  much  impaired.  He 
was  slightly  built,  not  so  fat  as  he  should  have  been  ;  his  pulse  very  weak, 
116;  and  his  temperature  99.6°,  and  100°  in  the  evening.  He  had  a 
warm  bath  at  98°,  with  cold  cloths  to  his  head  for  fifteen  minutes,  and  a 
draught  of  ten  grains  of  chloral,  and  forty-five  grains  of  bromide  of  po- 
tassium, with  two  drachms  of  tincture  of  valerian.  He  scarcely  slept  at 
all,  and  next  day  his  condition  was  still  most  excited  and  violent,  but  he 
was  kept  walking  about  by  two  attendants  for  five  hours,  though  very 
intractable,  throwing  himself  about,  etc.  Next  night  he  got  a  bath  for 
twenty  minutes,  and  the  same  draught,  and  slept  six  hours.  Next  day 
his  temperature  was  normal.  He  was  less  excited,  and  walked  better. 
The  same  treatment  was  continued,  and  in  three  days  he  was  still  better, 
and  in  eight  days  he  was  playing  cricket.  He  had  a  relapse  on  the  tenth 
day,  though  he  did  not  get  nearly  so  excited  as  at  first.  He  had  two  or 
three  milder  relapses  within  the  next  two  months,  but  at  the  end  of  that 
time  he  was  practically  well,  and  in  three  months  he  was  discharged  re- 
covered. His  treatment  consisted  of  an  almost  indefinite  allowance  of 
milk  and  eggs,  almost  no  animal  food,  fresh  air,  exercise  to  fatigue  all 
day,  baths,  warm  at  first,  and  mild  shower-baths  as  he  recovered,  and 
cod-liver  oil  emulsion,  with  the  hypophosphite  of  lime.  He  gained  al- 
most a  stone  in  weight,  but  did  not  grow  any  more  manly  in  his  form, 
nor  did  his  beard  grow. 

He  kept  well  enough  not  to  be  sent  to  the  asylum  for  three  and  a  half 
years,  but  during  that  time  he  constantly  had  threatenings  of  his  com- 
plaint, and  was  at  times  unable  to  follow  any  continuous  occupation. 
After  that  time  he  had  another  attack  of  a  much  more  mild  kind  of  acute 
mania.  He  was  delirious,  not  violent,  early  ceasing  to  take  any  interest  in 
anything ;  seeming  to  live  in  a  morbid  subjective  mental  atmosphere  of 
disordered  imagination  ;  talking  to  himself  incessantly,  not  sleeping  well, 
was  constantly  grimacing,  gesticulating,  and  fighting  imaginary  persons 
in  the  room  round  the  wall.  When  he  was  spoken  to,  he  would  pick 
himself  up  and  answer  pretty  rationally.  This  is  a  condition  that 
puzzles  many  persons.  It  looks  like  dementia,  while  in  reality  it  is  a 
subacute  form  of  mania,  which  makes  all  the  diiference  in  the  prognosis, 
and  sometimes  in  the  treatment.  He  Avas  tried  at  home,  in  charge  of  an 
attendant  to  control  him,  to  get  him  to  walk  out,  etc.,  but  he  rather 
rebelled.  Patients  are  of  course  never  so  easily  controlled  at  home 
as  away  from  it ;  especially  it  is  hard  for  the  master  or  mistress  of  a 
household  to  be  controlled  in  their  own  house,  where  before  every  one  was 
under  them.  In  an  institution,  on  the  contrary,  among  strangers,  under 
certain  definite  rules  of  living,  and  Avhere  there  is  obviously  the  means  of 
enforcing  medical  orders,  a  patient  must  be  very  insane  not  to  conform  to 
the  orders  given  as  to  his  treatment,  and  to  the  general  Avay  of  living  of 
the  place.     This  is  very  often  seen  when  patients  come  to  asylums.     At 


152  STATES    OF    MENTAL    EXALTATION. 

home  they  had  been  very  difficult  to  manage,  or  most  obstinate,  -while 
from  the  moment  they  come  into  the  institution  they  give  no  trouble  at  all. 

He  had  again  to  be  sent  to  the  asylum,  and  he  was  found  to  have  lost 
in  weight,  and  to  be  ill-nourished  and  "wanting  in  nervous  tone  and 
nutritive  energy.  His  muscles  were  flabby  and  his  skin  pale,  and  his 
appetite  for  food  not  keen.  He  was  put  on  quinine  and  iron,  cod-liver 
oil,  milk,  and  eggs  in  large  quantities,  his  skin  well  rubbed  night  and 
morning  with  a  dry  towel ;  he  got  mild  shower-baths,  and  took  much  and 
increasingly  vigorous  exercise.  He  gradually  gained  in  weight,  in 
nervous  tone,  in  self-control,  in  power  of  applying  himself  to  work, 
in  his  interest  and  power  of  attention ;  he  got  more  manly  in  form,  and 
filled  out  into  a  strong,  vigorous-looking  young  man.  It  took  him  ten 
months  to  recover.  This  was  a  case  in  Avhich  I  was  very  much  afraid  of 
dementia.  I  think  this  would  have  certainly  resulted  had  not  right 
treatment  been  vigorously  adopted.  In  such  a  case  the  brain  is  in  much 
the  same  state  as  in  certain  forms  of  dementia,  jilus  a  little  maniacal 
excitement — but  that  makes  all  the  difference. 

I  had  once  under  my  care — C.  N. — a  young  lady  of  twenty-three,  of  a 
nervous  diathesis,  and  with  a  strong  heredity  to  insanity,  Avho,  bathing 
while  menstruating,  became  slightly  depressed,  then  had  an  attack  of 
slight  exaltation  every  month,  followed  by  a  day  or  two  of  modified 
stupor,  at  the  time  she  should  have  menstruated,  but  did  not.  After  a 
few  months  menstruation  returned,  but  came  on  every  fortnight,  thus 
reducing  her  strength,  and  causing  anaemia.  At  the  usual  time  of  men- 
struation on  one  occasion  a  most  violent  attack  of  acute  mania  came  on, 
with  incoherent  delirium  and  such  excessive  violence,  that  she  nearly 
killed  a  relation.  Two  trained  female  attendants  could  not  control  her  at 
home.  Her  temperature  was  103°,  one  of  the  highest  I  ever  saw  from 
uncomplicated  brain  exaltation,  and  she  had  to  be  taken  to  the  asylum 
within  twenty-four  hours  after  the  commencement  of  the  attack.  For 
the  first  fortnight  she  remained  in  the  most  acute  state  of  excitement 
I  think  I  ever  saw.  It  took  five  attendants  to  restrain  her,  dress,  undress, 
and  have  her  walked  out,  which  we  did  every  day.  When  she  would 
not  walk  she  was  allowed  to  roll  on  the  ground.  She  soon  became  less 
excited,  but  at  the  next  menstrual  time  she  had  a  relapse,  and  was  as  bad 
as  on  admission.  Though  apparently  absolutely  delirious,  and  without 
power  of  attention  when  excited,  yet,  when  the  attack  passed  ofi", 
she  could  describe  what  had  occurred  very  accurately  for  the  most  part, 
though  distorted  in  some  respects.  She  had  no  realization  that  she  had 
been  so  ill,  and,  therefore,  thought  she  was  unnecessarily  detained  in  the 
asylum,  and  that  the  attendants'  restraint  of  her  violence  had  been  simple 
cruelty  on  their  part. .  There  is  a  psychological  fiict  with  which  we  are 
very  familiar  in  asylums,  which  was  most  marked  in  her  case,  though  it 
occurs  more  or  less  in  most  cases  of  mania  and  melancholia.  As  the 
patients  first  become  coherent  and  sensible,  they  are  much  more  unrea- 
sonable about  going  home  at  once,  and  about  getting  all  they  fancy,  and 
about  being  controlled,  and  about  all  sorts  of  things,  then  when  they  get 
quite  well.  They  usually  attribute  any  nervous  symptoms  they  have  to 
their  being  "kept  in  the  asylum,"  and  aver  with  daily  iteration  that,  if 
kept  much  longer  "in  a  madhouse"  or  "among  maniacs,"  they  will 


STATES    OF    MENTAL    EXALTATION.  153 

certainly  become  insane.  Their  friends  do  not  understand  that  this  is  the 
ordinary  half-way  house  to  complete  recovery,  and  sometimes  remove  them 
home,  often  with  very  bad  results.  When  they  have  quite  recovered,  such 
patients  are  commonly  patient  and  reasonable  about  going  home,  and 
often  recognize  hoAV  necessary  restraint  has  been.  Some  patients  never 
do  this,  however.  C.  N.  had  relapses  of  a  less  severe  character,  about 
the  menstrual  periods,  getting  more  and  more  reasonable  during  the 
intervals.  In  six  months  she  was  so  well  that  she  was  taken  home,  not 
exactly  against  my  advice,  but  not  quite  with  my  concurrence,  as  she  had 
not  menstruated,  and  was  excitable. 

The  question  of  when  recovery  has  taken  place  is  often  a  difficult  one 
to  decide  in  mental  diseases.  You  have  to  take  the  temperament,  dispo- 
sition, and  normal  state  of  mind  into  account.  The  same  standard  cannot 
be  applied  to  persons  of  different  education,  temperament,  or  nationality. 

The  relation  of  menstruation  to  mental  disease  is  a  very  important  one, 
of  which  I  shall  treat  more  fully  under  uterine  insanity  ;  but  I  may  say 
now  generally  that  in  most  cases  of  acute  mania  cessation  is  the  conse- 
quence, and  one  symptom  of  the  morbid  brain  excitation,  and  not  its 
cause,  and  the  restoration  of  the  function  is  the  result  of  improved  brain 
and  bodily  health  and  condition.  I  never  adopt  special  means  for  its 
restoration  until  the  patients  are  strong  and  have  become  fat,  but  at  the 
same  time  I  regard  mental  recovery  in  a  woman  as  being  likely  to  be 
much  more  stable  and  less  liable  to  relapse  after  the  menstrual  function 
has  become  normal.  I  always  like  to  see  it  normal  before  I  recommend 
the  patient's  removal  from  the  asylum. 

The  treatment  in  this  case  was  the  same  exactly  as  the  last.  Unfortu- 
nately, she  was  threatened  with  a  relapse  after  going  home,  but  it  was 
summer,  and  I  sent  her  to  vegetate  and  live  in  the  fresh  air  at  the 
seaside,  Avhere  her  recovery  was  completed.  She  then  went  to  work,  and 
worked  too  hard,  and  has  since  had  two  attacks  of  the  same  kind,  but  of 
shorter  duration  and  slighter  character,  in  the  four  years  that  have 
elapsed  since  her  first  recovery. 

Both  of  these  cases  (C.  M.  and  C.  N.),  though  cases  of  acute  mania 
in  the  classification  founded  on  mental  symptoms,  are  cases  of  the  insanity 
of  adolescence,  when  looked  at  from  the  clinical  point  of  view. 

Though  recovery  from  acute  mania  is  usually  a  gradual  process,  yet  at 
times  it  is  sudden.  Why  this  should  be  in  certain  patients  I  am  quite 
unable  to  tell,  nor  have  we  any  means  of  predicting  beforehand  in  any 
case  that  it  will  terminate  in  recovery  in  that  sudden  way.  This  is  an 
example,  which  was  cured  suddenly  by  a  local  inflammation  : 

C.  0.,  ret.  44,  a  married  woman,  with  several  children.  No  heredi- 
tary predisposition,  the  sole  cause  being  over-work  in  her  household  and 
over-anxiety  about  her  family.  She  was  of  an  "anxious  disposition" 
and  a  nervous  diathesis.  She  became  irritable,  quarrelsome,  restless, 
sleepless,  excited,  and  totally  changed  from  her  natural  ways  about  a 
week  before  her  admission,  and  this  condition  quickly  passed  into  one 
of  acute  maniacal  exaltation,  noisiness,  singing,  fleeting  delusions,  vio- 
lence, and  excitement,  with  no  memory,  no  self-control,  and  no  afiection 
for  her  children,  of  Avhom  she  had  been  passionately  fond.  Some- 
times she  would  be  perfectly  taciturn  and  obstinate  for  an  hour  or  two, 


154  STATES    OF    MENTAL    EXALTATION. 

would  not  open  her  eyes,  answer  questions,  eat,  or  walk  about.  She  had 
not  slept  for  several  nights  before  admission,  and  had  refused  food. 
When  brought  to  the  asylum  she  was  actually  excited,  noisy,  shouting, 
singing,  gesticulating,  struggling,  resisting,  violent,  making  faces  and 
facial  contortions,  putting  her  tongue  out,  but  would  not  answer  questions 
or  attend  to  anything  said  to  her.  The  common  sensibility  seemed  quite 
blunted,  so  that  she  felt  no  pain.  Her  skin  was  dry,  tongue  furred  and 
dry,  appetite  gone.  Pulse  126,  small  and  weak.  Temperature  101.2°. 
For  the  first  four  days  she  remained  in  this  state,  taking  scarcely  enough 
food,  and  that  with  extreme  difficulty,  and  spending  her  time  partly  out 
of  doors,  under  the  care  of  two  attendants,  and  partly  in  the  padded 
room  when  in  the  house.  On  the  fifth  day,  having  refused  food  altogether, 
she  was  fed  with  the  stomach-pump.  This  was  done  with  extreme  diffi- 
culty, on  account  of  her  holding  her  teeth  together  most  closely.  The 
steel  mouth-opener,  though  padded  with  tape,  she  crushed  through  a 
tooth  by  the  force  with  which  she  bit  it.  This  caused  a  good  deal  of 
inflammation  in  the  gums  and  jaw,  spreading  back  to  the  parotid  gland, 
which  became  enormously  swollen  and  suppurated.  But  as  the  inflam- 
mation spread  the  maniacal  condition  subsided,  so  that  on  the  tenth  day, 
when  the  temperature  Avas  106°,  and  the  patient  very  weak  and  exhausted 
indeed,  the  restlessness  and  excitement  had  quite  ceased,  and  she  took 
both  food  and  stimulants.  She  was  confused  in  mind,  but  not  otherwise 
maniacal ;  and,  though  she  nearly  died  from  the  combined  general 
exhaustion  and  local  inflammation,  she  never  became  maniacal  again, 
steadily  progressed  towards  recovery,  mental  and  bodily,  and  was  well 
in  a  month. 

This  is  one  example  of  very  many  cases  I  have  met  Avith,  where  a 
local  inflammation,  a  fever,  an  internal  disease,  a  carbuncle,  a  crop  of 
boils,  or  septic  blood-poisoning,  have  cured  insanity.  We  try  to  do  the 
same  thing  sometimes  in  cases  that  are  strong  in  body  by  severe  blister- 
ing, but  seldom  succeed  in  producing  the  same  marked  and  immediate 
effect.  I  believe  that  some  day  Ave  shall  hit  on  a  mode  of  producing  a 
local  inflammation  or  manageable  septic  blood-poisoning,  by  which  we 
shall  cut  short  and  cure  attacks  of  acute  mania.  I  have  been  most  im- 
pressed by  some  of  the  cases  I  have  met  with.  But  such  intercurrent 
diseases  do  not  always  cure.  I  have  often  seen  them  occur  in  cases  of 
acute  mania,  and  do  no  good.  I  suppose,  in  fact,  the  failures  may  be 
more  numerous  than  the  successes,  but  the  latter  naturally  make  more 
impression  on  one's  mind  and  loom  larger  in  one's  field  of  experience. 
The  following  Avas  a  most  striking  case  of  cure,  sudden  and  unexpected, 
after  hope  had  been  nearly  given  up : 

C.  P.,  set.  26.  A  married  woman  who  had  suffered  from  acute  mania 
connected  with  lactation  for  nine  months.  The  symptoms  had  come  to 
have  some  of  the  mental  enfeeblement  of  dementia  about  them ;  but  still 
there  was  the  maniacal  excitement,  the  presence  of  Avhich  prevented  in 
my  mind  an  absolutely  unfavorable  prognosis.  She  had  been  discharged 
from  another  asylum  as  virtually  incurable.  She  had  several  cuts  on  her 
hand  on  admission,  caused  by  her  having  broken  a  AvindoAV.  Fortunately 
for  her,  one  of  them  got  some  dirt  into  it,  and  the  hand  inflamed  badly, 
with  a  nasty  septic-looking  inflammation  that  ran  up  the  lymphatics,  and 


STATES    OF    MENTAL    EXALTATION.  155 

was  attended  by  intense  pain,  and  great  general  disturbance  and  prostra- 
tion. It  suppurated,  and  discharged  a  dirty,  sanious  pus.  But  the  effect 
on  the  brain  condition  was  magical.  This  nine  months'  maniacal, 
destructive,  dirty,  violent  woman,  caring  nothing  for  her  husband  or 
children,  or  the  common  decencies  of  life,  became  quite  gentle  and  man- 
ageable as  the  inflammatory  fever  and  the  local  inflammation  progressed. 
At  first  confused  in  mind,  then  awaking  to  all  the  former  associations  of 
her  life,  she  inquired  for  her  children,  and  became  in  a  fortnight  a  sane, 
pleasant,  lady-like  woman,  with  all  the  charms  and  graces  of  womanhood. 
Such  cases  puzzle  one  exceedingly.  That  period  of  nine  months,  during 
which  the  neurine  of  the  brain  convolutions  had  been  energizing  morbidly, 
so  that  every  mind  function — intellectual,  affective,  instinctive,  and 
mnemonic — was  utterly  disordered,  clearly  left  no  trace  of  structural 
change.  Unfortunately  I  have  to  give  the  sequel,  which  is  not  so 
pleasant.  She  kept  quite  well  for  three  years,  and  unluckily  had  a 
child,  and  while  nursing  it  (neither  of  which  she  ever  ought  to  have 
done),  another  child  died,  causing  her  great  grief.  She  again  became 
maniacal.  I  blistered  her  head  repeatedly  and  severely,  and  rubbed 
in  irritants  with  marked  benefit,  but  not  with  such  absolute  and  striking 
effect  as  on  the  first  occasion,  because  probably  I  could  not  set  up  a  real 
inflammatory  fever.  I  put  her  on  bromide  of  potassium  and  cannabis 
indica,  with  very  marked  benefit.  She  got  better  in  four  months,  and 
went  home  quite  well  in  all  respects.  In  a  year  she  became  maniacal 
again,  and  this  time  no  treatment  has  been  of  any  avail.  She  remains 
ill  for  over  two  years,  and,  I  fear,  is  now  incurable. 

The  good  effect  of  the  treatment  by  hot  baths  was  well  seen  in  the  fol- 
lowing case  of  C.  P.  A.,  a  young  man  who,  as  the  result  of  over-Avork, 
too  little  fresh  air  and  relaxation,  became  morbidly  exalted  in  mind, 
restless,  sleepless,  talkative,  and  changed  in  general  mental  demeanor. 
While  in  this  state  he  was  more  active  mentally  than  he  had  ever  been  in 
his  life.  He  wrote  an  article  for  the  most  brilliant  weekly  journal  of  the 
time,  which  was  accepted  and  inserted — the  only  article  he  ever  wrote  in 
his  life.  His  condition  soon  passed  into  violent  excitement,  constant 
extravagant  talking,  and  fleeting  delusions  of  ambition  and  extravagance. 
His  conduct  became  violent,  destructive,  and  unmanageable,  and  he  was 
in  that  condition  when  I  saw  him.  I  got  a  first-rate,  strong,  trained 
attendant,  and  we  give  him  two  baths  of  about  104°,  with  cold  to  his 
head.  The  immediate  effect  of  this  was  lowering,  and  he  nearly  fainted 
before  he  was  taken  out  of  the  second,  but  his  excitement  and  talkative- 
ness and  his  delusions  were  calmed  and  diminished.  He  got  drachm 
doses  of  the  bromide  of  potassium  repeated  three  times  during  the  night, 
and  for  the  first  time  for  about  ten  days  he  had  a  good  sleep.  By  the  way, 
I  should  have  mentioned  that  between  the  baths  he  was  taken  out  into  the 
open  air  and  walked  about  for  several  hours  till  he  was  pretty  nearly 
exhausted.  Next  morning;  all  the  most  violent  and  unmanageable  of  the 
symptoms  were  found  to  have  passed  off,  and  under  the  treatment  of  baths 
and  bromide,  with  plenty  of  exercise  and  unlimited  milk  and  liquid 
nourishment,  he  made  a  speedy  and  perfect  recovery  in  about  a  week  or 
ten    days  without  relapse   and  without   complication.     In  a  fortnight 


156  STATES    OF    MENTAL    EXALTATION. 

he  was  able  to  go  away  for  a  change,  and  has  since  been  as  vigorous  a 
man,  mentally  and  bodily,  as  he  ever  was,  conducting  a  large  business. 

Acute  mania  sometimes  exhausts  the  strength  of  the  patient,  and  kills 
in  spite  of  treatment,  as  in  the  following  case  of  C.  Q.,  set.  34,  suffering 
from  the  third  attack  of  mental  disease,  the  two  former  having  been 
attacks  of  melancholia.  She  had  a  sister  insane,  and  a  brother  an 
imbecile.  She  had  been  ill  for  about  a  month,  being  much  excited,  and 
refusing  food.  On  admission  she  was  acutely  maniacal  and  delirious, 
with  no  memory,  and  no  power  of  attention.  He  pulse  was  98,  her 
temperature  99.6°.  and  her  general  condition  weak.  She  refused  food, 
and  though  fed  regularly  with  the  stomach-pump,  the  excitement  con- 
tinued, and  she  got  more  and  more  exhausted,  though  after  the  first 
feeding  with  custard,  wine,  and  quinine,  she  was  less  excited,  and  slept 
for  the  first  time  for  a  week,  but  this  good  result  did  not  continue,  and 
she  died  on  the  fifteenth  day.  A  post-mortejn  examination  showed  the 
traces  of  old  morbid  action  in  the  shape  of  thickened  and  adherent  dura 
mater ;  the  vessels  of  the  brain  being  engorged ;  but  its  substance,  so  far 
as  our  means  of  investigation  enabled  me  to  examine  it,  was  normal. 
There  is,  of  course,  no  reason  why  a  mere  dynamical  brain  disturbance 
should  not  kill  and  leave  no  structural  trace,  any  more  than  that  it  should 
for  months  abolish  judgment,  affection,  and  memory,  and  then  pass  ofi" 
and  leave  the  brain  and  all  its  functions  intact.  The  most  common  post- 
mortem  appearances  in  the  brain  in  those  cases  that  die  of  acute  mania 
are  intense  hyperaeinic  conditions,  as  represented  in  Plate  III.  The  con- 
stant occurrence  of  such  hyperaemia  in  limited  areas  shows  that  the  vaso- 
motor disturbance  is  not  uniform  all  over  the  brain.  In  the  case  from 
which  Plate  III.  was  drawn,  the  congestion  occurred  along  the  whole 
inner  margin  of  the  gray  substance  of  the  convolutions  as  well  as  in  areas. 
I  have  always  looked  on  this  irregularity  of  blood-supply  to  the  brain, 
resulting  from  such  vaso-motor  spasm  at  some  parts,  and  paralysis  at 
others,  as  being  most  important  in  throwing  light  on  the  general  pathology 
of  acute  insanity,  but  I  do  not  regard  any  vascular  disturbance  as  a 
primary  cause  of  the  disease. 

The  following  case  of  acute  mania  was  caused  evidently  by  a  pathological 
deposit  of  a  kind  yet  undescribed  all  through  the  convolutions.  C.  Q.  A., 
set.  50,  had  been  insane  for  only  a  few  days,  and  was  acutely  excited  and 
maniacal  on  admission.  Her  temperature  was  98°,  and  her  pulse  88. 
She  was  deliriously  maniacal,  unconscious,  restless,  sleepless,  and  noisy. 
In  a  fortnight  she  became  more  rational  and  quiet,  and  could  do  some 
work.  Then  in  another  week  the  acute  deliriously  maniacal  condition 
returned.  She  got  more  stupid  and  irrational,  and  died  four  weeks  after 
admission,  and  five  weeks  after  the  commencement  of  her  insanity. 
With  the  late  Dr.  Joseph  J.  Brown,  then  the  assistant  physician  in  charge 
of  the  department,  I  made  the  post-mortem  examination  ;  and  the  naked- 
eye  appearances  were,  like  the  microscopic  appearances  afterwards 
discovered  by  Dr.  Brown,  quite  unique  and  hitherto  undescribed.  The 
pia  mater  was  milky  and  thickened,  and  stripped  readily  off  the  convolu- 
tions. Convolutions  were  somewhat  atrophied.  In  the  convolutions 
around  the  island  of  Reil  there  were  seen  a  number  of  small  pellet-like 
bodies  the  size  of  pin-heads,  and  of  a  glistening  appearance,  scattered. 


PLATE  III. 


James    Rol'ertsca,  Dei: 


C  W4ters'.oii  iSons.  Litic ,  Edipbur^ 


STATES    OF    MENTAL    EXALTATION".  157 

When  closely  examined  it  was  seen  that  these  sago-like  bodies  were  more 
or  less  distributed  over  the  gray  substance  of  nearly  the  whole  of  the  con- 
volutions of  the  cerebrum.  The  outer  layer  of  the  gray  matter  of  the 
convolutions  was  quite  distinct  from  and  stripped  like  a  sheet  of  wet  paper 
off  the  under  layer.  Dr.  Brown  prepared  many  beautiful  sections  of  the 
convolutions  so  affected,  and  was  to  have  fully  described  the  lesion,  which 
Avas  new  and  most  interesting.  A  deposit  of  a  new  material  had  taken 
place,  as  represented  in  Fig.  5,  Plate  VIII.,  all  through  the  gray 
substance  of  the  convolutions,  but  chiefly  in  its  inner  layers,  and  extend- 
ing in  some  parts  into  the  Avhite  substance.  It  was  in  some  places  in 
single  spots,  with  a  nucleus  in  the  centre  of  each,  but  no  other  trace 
of  organization  visible ;  in  other  places  in  immense  lobulated  masses,  or 
in  great  oval  bodies  with  a  nucleus  in  the  centre  of  each,  quite  visible  to 
the  naked  eye.  It  was  deposited  in  masses  round  the  arteries  in  many 
places.  It  seemed  as  if  at  the  least  two-thirds  of  all  the  gray  substance 
of  the  convolutions  were  replaced  by  this  deposit.  It  took  on  the  carmine 
stain  strongly,  and  looked  more  like  a  waxy  material  than  anything  else, 
but  its  exact  composition  I  do  not  know.  It  was  evident  that  it  was  a 
chemico-vital  product  deposited  round  nuclei. 

Many  questions  suggest  themselves  in  considering  such  a  case.  What 
a  comfort  it  would  be  were  the  pathology  of  every  case  of  acute  mania  as 
definite  as  this  seemed  to  be !  The  discouraging  thing  is,  that  no  such 
deposit  is  needed  at  all  to  produce  mental  symptoms  like  those  of  C.  Q.  A. 
How  long  was  this  deposit  in  forming  ?  Surely  longer  than  the  five 
weeks  she  was  insane.  And  she  became  wonderfully  rational  and 
coherent  after  the  first  three  weeks  with  her  brain  convolutions  diseased 
in  this  way,  just  as  a  general  paralytic  often  gets  almost  rational  for 
a  time  with  his  convolutions  diseased.  It  is  clearly  not  only  a  deposit  of 
this  kind,  or  a  pathological  change  in  the  cells,  but  the  morbid  energizing 
that  such  lesions  give  rise  to,  that  really  produce  the  symptoms  of  acute 
mania. 

Delusional  Mania. — This  is  a  condition  analosous  to  what  I  have 
described  as  delusional  melancholia,  the  general  symptoms  being  maniacal 
instead  of  melancholic,  and  centring  round  a  fixed  delusion  or  set  of 
delusions.  I  have  now  under  my  care  a  woman — C.  Q.  B. — who  shouts, 
scolds,  and  is  violent  almost  all  day,  alleging,  as  the  reason  of  her  con- 
duct, that  her  children  are  below  the  boards  of  the  floor,  and  that  she 
hears  them  being  tortured  by  villains,  who  are  to  kill  them.  I  have  a 
man  who  shouts  and  preaches,  and  warns  the  sinners  of  the  world  in  a 
most  riotous  and  noisy  way  of  the  doom  that  awaits  them,  saying  that 
the  Lord  had  commissioned  him  to  do  so.  Delusional  mania  is  in  fact 
delusional  insanity,  plus  maniacal  conduct.  Such  cases  sometimes 
recover,  but  when  the  fixed  delusional  condition  has  lasted  long  the  prog- 
nosis is  bad. 

Chronic  Mania. — This  is  simply  acute  mania  running  on  into  a 
chronic  course.  The  division  line  that  marks  off  acute  from  chronic 
mania  must  always  be  an  imaginary,  arbitrary,  and  unscientific  one. 
The  term  of  twelve  months  that  I  have  adopted  has  this  disadvantage, 
that  after  that  time  many  cases  are  curable,  while  we  usually  think  of 
chronic  mania  as  being  virtually  an  incurable  disease,  ending  in  death  or 


lo8  STATES    OF    MENTAL    EXALTATION. 

dementia.  The  long  continuance  of  a  maniacal  condition  of  the  brain 
always  causes  an  alteration  of  the  symptoms,  as  compared  with  those  of 
recent  acute  mania.  We  seldom  or  never  have  any  tendency  to  delirious 
mania,  with  dry  tongue,  high  temperature,  and  risk  to  life,  from  the 
intensity  of  the  disease.  To  be  able  to  live  long,  suffering  from  chronic 
mania,  implies  a  strong  constitution,  with  good  digestive  and  assimilative 
power.  Though  the  absolute  sleeplessness  of  acute  mania  is  not  present, 
yet  many  cases  of  chronic  mania  sleep  exceedingly  little.  It  may  seem 
incredible,  but  we  had  once  at  Morninorside,  a  woman  suflferincr  from 
chronic  mania,  who  for  eighteen  months  was  never  found  asleep  by  the 
night  attendant,  who  visited  her  eveiy  two  hours  every  night.  She 
must  have  slept,  of  coui-se,  but  her  sleep  was  so  light  and  so  short  that 
she  was  always  awake  every  two  hours.  Not  only  did  she  not  sleep,  but 
she  was  restless,  noisy,  singing,  tearing  her  bedding,  and,  when  she  had 
nothing  else  to  do,  gnawed  with  her  teeth  and  scratched  with  her  nails 
the  wood-work  of  her  room  into  great  holes.  But  some  cases  of  chronic 
mania  sleep  quite  well,  and  almost  the  natural  time,  and  yet  during  the 
day  they  continue  excited,  restless,  and  destructive. 

There  is  usually  a  spice  of  the  enfeeblement  of  mind  of  dementia  in 
chronic  mania,  notably  the  memory  is  impaired,  a  rational  interest  in 
anything  cannot  be  roused,  and  the  habits,  instincts,  and  fine  feelings  are 
degraded  or  dulled.  The  affective  power  is  usually  almost  paralyzed. 
There  is  no  proper  care  for  children  or  tender  affection  for  anybody. 

As  regards  treatment,  an  asylum  is  the  only  proper  place  for  such 
patients.  I  have  seen  them  kept  at  home,  or  boarded  in  private  houses, 
but  I  have  seldom  seen  a  patient  very  happy  there,  or  the  arrangement 
very  satisfactory.  I,  shall  never  forget  a  visit  I  once  paid  to  a  case  suf- 
fering from  chronic  mania — C.  R. — with  short  aggravations  each  day  of 
wild  delirious  fury.  To  provide  against  these,  two  large  rooms  in  a 
handsome  villa  had  been  divested  of  furniture,  the  windows  boarded  up, 
and  the  walls  left  to  the  unrestrained  destructiveness  of  the  patient.  I 
stayed  with  her  in  this  apartment  during  a  paroxysm  of  her  disease,  and, 
in  twenty-two  years  of  life  as  an  asylum  physician,  I  have  never  seen 
anything  so  completely  parallel  to  the  famous  maniac  scene  in  Charlotte 
Bronte's  Jane  Eyre.  The  patient  tore  her  clothes  to  ribbons,  shouted 
and  howled,  and  made  a  barking  noise  like  a  dog,  bit  her  skin,  dashed 
herself  against  the  Avails,  and  dug  into  the  plaster  and  wood-work  with 
her  nails  till  they  bled,  and  she  smeared  the  blood  over  her  face  and  body. 
After  many  years  of  this  life,  her  relatives  at  last  got  over  their  preju- 
dices against  an  asylum,  and  sent  the  patient  to  Morningside,  where,  after 
a  few  months  of  hard  walking  in  the  open  air,  occupation,  dancing,  and 
a  regulated  life,  she  is  an  oi-namental  and  amusing  member  of  our  com- 
munity, very  happy,  and  always  averse  to  the  idea  of  leaving  the  asylum. 
She  takes  her  paroxysms  still,  but  they  are  shorter  and  much  less  severe, 
and  her  attendant  stays  with  her,  which  soothes  her.  One  of  the  great 
improvements  that  has  taken  place  in  modern  asylum  management  has 
been  that  rational  physiological  outlets  are  provided  for  the  morbid  mus- 
cular energy  of  the  cases  of  chronic  mania.  They  are  neither  confined 
in  their  rooms  nor  within  "  airing  courts  "  enclosed  by  high  walls.  They 
arc  made  to  walk  about.     They  are  made  to  wheel  barrows  and  dig  on 


STATES    OF    MENTAL    EXALTATION.  159 

farms.  They  are  encouraged  to  dance,  and  tliey  are  well  fed.  jMost  of 
them  eat  enormously,  and  if  they  have  not  enough  to  eat  they  fall  oft",  get 
worse  in  their  mental  state  and  in  their  habits.  Many  of  them  can  be 
got  to  expend  their  energies  in  hard  regulated  work,  and  are  the  very 
best  workers  on  the  forms  and  in  the  laundries  of  asylums.  They  are 
not  all,  of  course,  furiously  maniacal.  Some  of  them  simply  have  a 
slight  morbid  excess  and  exaltation  of  function  of  the  brain  convolutions, 
shown  by  restlessness,'  want  of  affection,  and  want  of  self-control,  but  are 
not  incoherent.  If  they  are  kept  at  work,  the  most  objectionable  and 
repulsive  parts  of  the  older  asylum  life  is  avoided  in  great  measure,  and 
the '"  refractory  wards,"  with  their  noise  and  danger,  are  not  needed. 
The  scenes  with  patients,  attendants  holding  them  down  and  removing 
them  into  the  seclusion  of  their  own  rooms,  are  few.  No  doubt  there  are 
risks  run  in  the  present  system  to  patients  and  their  guardians,  but  I 
believe  the  risks  are  much  less  in  reality  than  under  the  old  system,  for 
the  patients  are  not  so  irritable,  not  so  revengeful,  and  not  so  dangerous 
generally. 

The  following  was  a  case  of  mania,  acute  at  first,  with  temporary 
recovery,  then  a  relapse,  and  chronic  mania  for  three  years,  then  death ; 
all  the  mental  symptoms  being  those  of  the  ambitious  delirium  of  general 
paralysis. 

C.  Y.,  aet.  67.  A  man  of  sanguine  temperament,  very  frank  and 
enthusiastic  disposition,  and  industrious  habits.  For  many  years  he  had 
devoted  himself  with  zeal,  enthusiasm,  and  industry,  as  to  a  real  business 
in  life,  to  the  study  of  a  particular  department  of  knowledge,  until  he 
was  one  of  the  acknowledged  authorities  on  the  matter.  He  was  a  man 
of  much  individuality  of  character,  amounting  almost  to  eccentricity,  and 
he  evidently  had  a  high  opinion  of  himself  and  of  what  he  had  done. 
His  habits  were  so  industrious  in  following  his  special  work  that  he  gave 
himself  too  little  sleep,  and  this,  I  think,  was  the  exciting  cause  of  the 
attack  I  am  about  to  describe ;  the  predisposing  cause  being  a  heredity  to 
the  neuroses,  which  some  of  his  friends  Avere  so  anxious  to  deny,  that  I 
concluded  it  must  exist ;  in  fact,  I  had  evidence,  by  seeing  some  of  them, 
of  its  existence.  His  disease  consisted  of  a  gradual  evolution  and  exag- 
geration of  certain  points  in  his  character  into  excessive  and  morbid 
prominence.  His  good  opinion  of  himself  and  the  value  of  his  work, 
which  before  had  merely  been  apparent  in  small  things,  now  became 
evident  beyond  what  sensible  men  ordinarily  display.  He  became  rest- 
less; his  sleep  power  seemed  to  have  gone,  so  that  he  sat  up  all  night, 
and  he  became  irritable  without  reason.  He  went  about  among  his 
friends,  and  talked  all  the  time,  his  natural  enthusiasm  about  his  special 
work  taking  ridiculous  forms.  He  developed  openly  an  idea  that  he 
seems  to  have  had  vaguely  held,  but  did  not  speak  about  it,  that  he  was 
the  heir  of  a  great  Scotch  historical  house.  In  a  certain  nascent  degree, 
the  idea  that  they  are  the  heirs,  or  at  all  events  the  members,  of  great 
historical  families,  is  a  most  common  psychological  peculiarity  of  vast 
numbers  of  perfectly  sane  Scotchmen ;  and  when  they  have  attacks  of 
morbid  mental  exaltation  this  vague  fancy,  and  perhaps  longing,  which 
before  had  no  more  practical  eff"ect  on  their  lives  than  heightening  their 
self-respect,  becomes  a  foolishly  expressed  delusion.     If  I  have  had  one 


160  STATES    OF    MENTAL    EXALTATION. 

Lindsay  as  a  patient  who  was  the  rightful  heir  to  the  earldom  of  Balcar- 
res,  I  have  had  certainly  a  dozen.  In  about  a  fortnight  C.  Y.  was 
absolutely  incoherent,  swearing,  and  fancying  he  was  in  heaven,  this 
condition  being  attended  with  great  violence  to  those  about  him.  and 
destruction  of  objects  that  he  had  valued  most  highly.  In  another  day 
or  two  he  became  quite  delirious,  and  he  would  take  no  food,  and  had  to 
be  sent  to  the  asylum.  On  admission  he  was  maniacal  and  furious, 
attacking  those  near  him  very  violently,  and  at  times  dashing  himself  on 
the  floor  in  a  way  that  might  have  hurt  him.  He  was  almost  incoherent, 
but  his  ideas  were  all  most  exalted.  He  had  millions  of  money,  could 
make  us  all  dukes,  etc.  He  would  make  a  man  a  duke  one  moment,  and 
strike  him  suddenly  the  next.  His  case  was  certainly  very  exceptional 
in  its  tendency  to  impulsive  violence.  He  was  in  this  respect  more  like 
the  dangerous  maniac  of  the  popular  imagination  than  most  of  our 
ordinary  patients.  With  this  intense  excitement,  and  with  much  mus- 
cular strength,  his  pulse  was  feeble,  his  tongue  dry,  his  face  haggard,  and 
his  whole  bodily  condition  one  of  great  weakness  and  danger  to  his  life. 
By  dint  of  feeding,  stimulants,  and  taking  him  into  the  open  air  under 
the  charge  of  tried  attendants,  he  gi*adually  improved.  His  mental  state 
was  all  the  time  exactly  that  intense  exaltation,  that  morbid  mental 
"expansion,"  that  "ambitious  delirium,"  or  ''mania  of  grandeur,"  which 
we  tind  so  commonly  in  general  paralysis,  and  which  some  physicians 
suppose  to  be  characteristic  of  that  disease.  Everything  about  the  place 
was  of  the  finest,  his  treatment  was  very  skilful,  the  physicians  were 
most  eminent,  and  the  attendants  were  most  kind.  In  the  beginning  of 
his  disease  I  often  was  on  the  look-out  for  the  motor  symptoms  of  general 
paralysis,  without  which  it  is,  of  course,  utterly  unjustifiable  to  diagnose 
that  disease.  In  three  months  he  had  become  quiet  in  manner,  self-con- 
trolled, and  rational,  but  had  just  a  suggestion  of  his  former  state  of 
mind  in  being  too  pleased  with  things,  and  too  grateful  for  little  kind- 
nesses. His  friends  thought  him  quite  well,  and  he  was  removed  home 
with  my  approval.  But  he  had  not  been  home  a  day  when  he  set  to 
work  to  his  old  employment  and  studies  Avith  a  sort  of  unreasonable 
enthusiasm.  Sitting  up  nearly  all  night,  he  soon  got  unsettled,  his 
exaltation  of  mind  came  back ;  he  became  dirty  in  his  habits,  impulsive, 
and  utterly  impatient  of  contradiction.  If  his  orders  were  not  at  once 
carried  out,  he  would  get  into  a  sort  of  maniacal  rage.  In  seventeen 
days  he  had  to  be  removed  back  to  the  asylum,  and  though  not  so  deli- 
rious or  so  weak  as  on  his  first  admission,  he  Avas  very  excited.  He  would 
come  up  and  be  most  please<l  to  see  you,  and  in  a  moment,  sometimes 
with  some  little  provocation,  such  as  your  not  agreeing  at  once  with  him 
that  he  was  an  Earl,  or  sometimes  without,  he  would  strike  you  suddenly, 
very  often  going  down  on  his  knees  immediately  after,  and  in  a  theatrical 
manner  begging  your  pardon,  and  hoping  he  had  not  ofiended  you.  In 
meeting  you  he  would  come  up  with   a  profound  bow,  place  his  hand 

on  his  breast,  and  hope  "Sir is  well."     His  insane  grandeur  of 

manner  was  often  very  grotesque.  He  would  talk  for  a  minute  in  this 
high-flown  way,  and  ask,  perhaps,  for  a  book  or  a  newspaper.  When  he 
got  it,  he  would  turn  round,  and  in  a  surreptitious  way  would  tear  it  up. 
He  was  given  to  impish  tricks  and  mischief  of  all  kinds.     His  habits 


STATES    OF    MENTAL    EXALTATION.  161 

were  dirty  in  the  extreme ;  he  tore  his  clothes  and  his  bedding,  and  he 
never  could  be  left  for  a  moment  without  his  getting  into  some  mischief. 
He  reminded  me  of  the  clown  in  a  pantomime,  only  combining  with  his 
mischief  a  far  more  magnificent  manner  than  any  clown  could  assume. 
This  went  on  in  spite  of  all  treatment,  medical,  moral,  or  dietetic,  for 
three  years,  at  the  end  of  which  time  he  died  of  internal  cancer.  The 
chronic  mania,  no  doubt,  weakened  his  brain  functions,  and  he  presented 
some  few  of  the  symptoms  of  brain  enfeeblement  towards  the  end.  His 
memory  was  worse,  he  was  not  so  coherent,  he  was  more  silly  and  childish 
in  his  ways,  and  the  maniacal  symptoms  were  not  quite  so  intense. 

On  post-mortem  examination  we  found  some  thickening  of  the  mem- 
branes, some  convolutional  atrophy,  some  disease  of  the  coats  of  the  ves- 
sels, some  local  congestions,  and  some  few  spots  of  ramollissement,  but 
nothing  pathognomonic,  nothing  so  characteristic  that  by  seeing  it  one 
could  say  that  the  man  labored  under  chronic  maniacal  exaltation.  This, 
of  course,  merely  shows  the  insufficiency  of  our  present  means  of  brain 
examination,  for  assuredly  there  must  have  been  organic  changes  after 
so  long  a  disturbance  during  life.  That  any  pathological  changes  will 
ever  show  the  special  mental  |3«culiarities  of  such  a  person,  his  ambitious 
mania,  his  lofty  opinion  of  himself,  his  destructive  tendencies,  is  more 
than  we  can  expect,  for  such  things  were  the  evolutions  of  his  tempera- 
ment and  the  skeleton  of  his  normal  mental  framework,  which  the  self- 
control  that  we  call  sanity  and  the  customs  of  civilized  life  induce  men 
to  hide  and  keep  under,  just  as  they  do  their  day  dreams  and  their  pet 
ambitions.  The  onset  of  the  cancer,  with  its  cachectic  and  exhaustive 
tendency,  may  have  been  the  exciting  cause  of  the  maniacal  attack,  and 
also  the  reason  why  recovery  did  not  take  place. 

The  chances  of  recovery  from  mania  after  twelve  months'  duration 
diminish  very  much  as  time  goes  on,  more  so  than  in  the  case  of  melan- 
cholia ;  but  we  do  not  pronounce  a  case  incurable  for  a  long  time,  so 
long,  in  fiict,  as  the  morbid  brain  exaltation  lasts,  and  dementia  does  not 
supervene.  In  the  prognosis  of  mania,  where  there  is  exaltation  there 
is  hope.  I  had  a  patient — C.  Y.  A. — discharged  recovered  two  years 
ago  Avho  had  been  for  eight  years  suffering  from  chronic  mania  of  an  ex- 
tremely bad  type,  with,  as  I  thought,  many  of  the  signs  of  dementia. 
I  had  sliOAvn  her  to  my  clinical  class  on  several  occasions  as  a  typical 
case  of  chronic  mania.  The  chances  of  recovery  are  in  inverse  ratio  to 
the  length  of  the  disease  after  the  first  two  years.  After  five  years  re- 
covery is  the  rare  exception ;  but  I  have  known  it  take  place  after  even 
twenty  years. 

Ephemeral  Mania  (Mania  Transitoria). — This  term  is  used  to 
describe  a  somewhat  rare  form  of  maniacal  exaltation  which  comes  on 
suddenly,  is  usually  sharp  in  its  character,  and  accompanied  by  incoher- 
ence, partial  or  complete  unconsciousness  of  familiar  surroundings,  and 
sleeplessness.  An  attack  may  last  from  an  hour  up  to  a  few  days.  I 
Avas  once  called  in  to  see  a  young  man  in  Carlisle,  C.  Z.,  a  patient  of  the 
late  Mr.  Robert  Brown,  who  suddenly,  without  premonitory  symptoms 
and  without  any  apparent  cause,  had  in  the  afternoon,  in  the  midst  of 
his  work,  become  incoherent  in  his  speech,  talking  continuously,  restless, 
pushing  about  the  furniture,  did  not  know  his  relations,  and  expressed 

11 


162  STATES    OF    MENTAL    EXALTATION. 

many  fleeting,  unconnected  delusions.  He  was  not  very  violent  or  diflfi- 
cult  to  manage.  He  would  take  no  food  or  medicine,  and  there  was  no 
means  of  making  him  do  so,  and  no  warm  bath  to  be  got,  so  he  was  left 
alone  under  the  charge  of  an  attendant.  He  did  not  sleep  that  night, 
but  towards  morning  he  became  less  talkative  and  restless,  he  began  to 
know  those  about  him,  then  there  was  an  hour  or  two  of  stupidity,  con- 
fusion, and  lethargy,  and  next  day  by  mid-day  he  was  himself  again, 
went  to  his  work,  and  had  no  relapse.  That  was  the  first  case  of  the 
kind  I  had  ever  seen,  and  it  was  very  instructive  to  me,  for  I  always 
since  ask  myself,  when  called  into  any  suddenly  occurring  case  of  mania, 
Is  it  a  case  of  mania  transitoria  ?  Since  then  I  have  met  with  many 
somewhat  similar  cases,  both  among  patients  who  were  convalescent  in 
the  asylum,  especially  among  epileptics,  and  also  in  the  patients  who 
were  not  in  the  asylum.  I  think  cases  of  mania  tranutoria  result  from 
the  following  causes.  Most  of  them  are  epileptiform,  are,  in  fact,  of  the 
nature  of  the  mental  epilepsy  of  Hughlings  Jackson  in  cases  where  dis- 
tinct motor  epilepsy  does  not  exist.  I  believe  the  case  of  C.  Z.  was  of 
this  character.  Others  are  examples  of  the  epilepsie  larvee  of  Morel, 
masked  epilepsy,  where  a  mental  explosion  takes  place,  instead  of  an 
ordinary  epileptic  fit.  A  few  of  the  cases  result  in  young  persons  from 
slight  moral  or  physical  causes  upsetting  brains  of  intense  instability 
that  have  strong  neurotic  heredity.  There  are  some  such  brains  so  easily 
upset  that  a  gust  of  passion,  a  sudden  stoppage  of  menstruation,  a  slight 
excess  of  alcohol,  of  sexual  intercourse,  or  of  masturbation  will  make 
them  delirious,  and  this  may  only  last  for  a  short  time.  All  the  symp- 
toms of  mania  transitoria  may  be  seen  in  the  incubation  of  and  during 
febrile  and  inflammatory  complaints,  such  as  scarlet  fever,  typhus  and 
typhoid,  local  inflammations,  etc.,  in  unstable  brains  that  are  upset  by 
very  little,  through  a  process  of  what  the  older  authors  called  metastasis. 
I  have  seen  ephemeral  mania  after  erysipelas. 

The  great  question  in  regard  to  ephemeral  mania  is  this — Can  we  tell 
it  by  any  special  symptoms  ?  There  are  no  definite  symptoms  that  I 
know  by  which  we  can  tell  that  any  maniacal  attack  is  going  to  be 
ephemeral.  There  is  always  a  presumption  that  when  an  attack  begins 
very  suddenly,  it  may  end  suddenly,  and  if  such  an  attack  occurs  in  a 
young  subject  with  strong  heredity  to  insanity,  whose  diathesis  has  been 
very  neurotic,  and  whose  brain  has  manifested  unstable  tendencies,  it  is 
right  to  keep  this  form  of  mania  in  mind,  and  not  be  in  too  great  a  hurry 
in  sending  such  a  case  to  an  asylum.  The  treatment  is  the  same  as  that 
I  have  recommended  for  acute  mania,  only  the  bromides  and  cold  appli- 
cations to  the  head  are  especially  indicated.  I  imagine  that  family  doc- 
tors who  attend  many  nervous  families  could  tell  of  attacks  of  what  are 
really  ephemeral  mania,  but  are  naturally  called  by  all  sorts  of  euphem- 
isms, "nervous  attacks,"  "hysterical  attacks."  I  once  saw  an  attack  of 
ephemeral  mania  come  on  and  last  a  few  hours,  in  a  girl  who  had  usually 
exhibited  her  neurosis  by  attacks  of  hysteria. 

Homicidal  Mania. — In  popular  and  sometimes  in  medical  phrase- 
ology, "homicidal  mania"  means  any  kind  of  mental  disease  where  there 
is  any  attempt  or  desire  on  the  part  of  a  patient  to  kill.  But,  as  you 
have  seen,  the  homicidal  desire  may  occur  in  melancholia,  and  is  often 


STATES    OF    MENTAL    EXALTATION.  163 

associated  with  the  suicidal  feeling.  As  we  shall  see,  it  may  occur  as  an 
uncomplicated  impulse,  not  accompanied  by  depression  or  exaltation  of 
mind,  and  it  then  stands  as  one  of  the  varieties  of  impulsive  insanity. 
But  at  present  we  are  to  view  it  as  one  of  the  chief  symptoms  of  certain 
forms  of  maniacal  exaltation.  In  this  it  occurs  in  four  forms:  First, 
and  most  commonly,  fi'om  delusion ;  e.  g.,  that  persons  attacked  are  per- 
secuting the  patient,  or  are  going  to  kill  him.  Second,  from  sheer  ex- 
cess of  motor  energy,  which  vents  itself,  as  it  were,  in  killing,  as  it  does 
more  ordinarily  in  smashing,  fighting,  or  tearing.  Third,  from  a  distinct 
morbid  desire,  impulse,  and  craving  to  kill.  Fourth,  homicidal  attacks 
are  made  in  the  unconscious  delirium  of  acute  delirious  mania  without 
"motive,"  without  "intent."  Of  the  first  kind  was  the  case  of  C.  N. 
(p.  149),  Avhen  she  attacked  the  attendant  on  admission,  under  the  delu- 
sion that  she  was  her  enemy  and  going  to  injure  her. 

We  had  in  Morningside  Asylum,  when  I  was  an  assistant  physician 
there  in  1860,  a  remarkable  case  of  homicidal  mania,  a  most  graphic 
account  of  which  was  published  by  my  friend  and  then  colleague,  Dr. 
Yellowlees.^  The  man's  name  was  Willie  Smith,  who,  beginning  with 
an  attack  of  what  was  evidently  simple  mania  in  1829,  and  taking  to 
publishing  his  own  effusions,  wrote  thus : 

"  There's  Willie  Smith  the  carpenter, 
Become  at  hist  a  publisher ; 
You'll  find  his  works  in  rhyme  and  prose 
Throughout  this  land  o'  cakes  and  brose  ;  " 

and  because  his  contemporaries  laughed  at  him,  and  the  boys  called  him 
"Whisker  Willie,"  broke  his  glass,  and  blew  "smoke  out  of  a  horn  full 
of  lighted  tow  into  my  shop,"  he  applied  to  the  law.  And,  by  the  way, 
what  a  psychological  study  is  the  boy's  instinct  in  finding  out  weak  points 
of  inhibition,  his  altogether  uncontrollable  impulse  to  probe  them  when 
found,  and  his  delight  at  the  result !  And  the  magistrates  would  give 
Willie  no  redress.  Because  of  these  things,  he  imagined  he  was  perse- 
cuted, and  planned  to  execute  revenge  all  the  rest  of  the  thirty-two  years 
of  his  life.  He  was  a  perfect  example  of  the  French  megalomania — ele- 
vated ideas  about  himself  and  his  powers,  combined  with  ideas  of  perse- 
cution— and,  in  addition,  with  strong  and  persistent  homicidal  tendencies. 
With  loaded  guns,  daggers,  spears,  axes,  swords,  extemporized  weapons 
of  all  sorts,  he  meditated  and  tried  revenge  and  homicide.  In  the  gaol, 
the  poorhouse,  the  asylum,  he  made  repeated,  persistent,  and  numerous 
attempts  to  murder  attendants  and  physicians,  and  was  the  terror  of  all 
who  knew  him.  "It  is  scarcely  possible  to  find  language  strong  enough 
to  describe  the  bloodthirsty  passion  which  possessed  the  man,  the  devilish 
intensity,  deliberation,  and  determination  with  which  all  his  attacks  were 
made,  or  the  fiendish  delight  with  which  he  gloried  in  relating  them." 
Yet  all  the  time  he  had  "  exaltation  of  the  feeling  of  pride,  and  high 
ideas,  and  delusions  regarding  his  own  powers  and  capabilities,  particu- 
larly as  an  engineer,  architect,  and  musician."  A  visit  to  him  was  the 
sight  of  the  asylum,  and  a  thing  to  be  remembered  for  many  years.     I 

^  Edin.  Med.  Journ.,  August,      62. 


164  STATES    OF    MENTAL    EXALTATION. 

do  not  know  how  it  is,  but  such  picturesque  cases  of  insane  would-be 
murderers  do  not  seem  to  occur  now.  The  fewer  precautions  are  taken, 
the  less  need  there  seems  to  be  for  them.  Wlien  he  died  his  head  was 
found  to  have  undergone  great  changes  in  shape,  as  compared  with  a  cast 
taken  twenty  years  before,  and  his  brain  was  much  atrophied. 

I  had  a  patient  once,  C.  Z.  A.,  set.  about  28,  with  a  strong  heredity 
towards  mental  disease,  who  had  been  working  too  hard  at  brain  work 
that  was  uncongenial  to  him,  and  also  had  had  a  disappointment,  and  who 
had  previously  shown  only  a  little  mental  confusion  for  a  week,  when 
suddenly,  without  warning,  he  made  a  homicidal  attack  on  his  brother 
when  taking  a  walk,  under  the  delusion  that  his  brother  wanted  to  do  him 
harm.  This  was  really  the  first  distinct  symptom  of  an  attack  of  sub- 
acute mania.  There  were  strong  reasons  why  he  should  not  be  sent  to 
an  asylum,  and  I  got  a  fii-st-rate  attendant  for  him,  who  kept  him  out  in 
the  open  air,  walking,  fishing,  etc.,  for  ten  hours  a  day.  I  put  him  on 
milk  diet,  with  warm  baths,  Pamsh's  syrup,  occasional  draughts  of 
bromide  of  potassium  and  chloral  at  night,  and  used  occasional  blisters  to 
his  head.  He  used  often  to  attack  his  attendant  fi'om  delusions  about 
him,  who,  however,  never  lost  his  nerve,  and  was  not  afi-aid  of  him.  He 
always  apologized  afterwards.  Gradually  the  excitement  passed  ofi",  and 
in  about  eight  months  he  recovered.  A  certain  mental  irresolution  and 
tendency  to  change  was  the  last  symptom  to  disappear,  as  is  the  case 
commonly  in  mental  disease.  A  perfect  power  of  volition,  spontaneity, 
the  power  to  originate,  is,  in  fact,  the  highest  mental  faculty,  and  is  the 
last  to  return  and  the  most  apt  to  be  left  impaired.  I  could  scarcely 
have  believed  at  one  time  that  such  a  patient  as  C.  Z.  A.  could  possibly 
or  safely  be  treated  out  of  an  asylum. 

The  second  kind  of  maniacal  homicidal  attacks,  viz.,  that  from  sheer 
excess  of  motor  energy,  is  often  seen  both  in  acute  and  chronic  cases. 
We  had  a  young  man,  C.  Z.  B.,  in  the  asylum,  who,  when  he  first 
became  insane,  attacked  a  man  on  the  street,  and  got  his  own  eye  knocked 
out,  and  for  many  years  did  little  by  night  and  day  but  groan  and  shout 
in  crescendo  movement,  box  the  walls  so  that  his  hands  and  knuckles 
were  hard  as  horns,  swollen,  and  oft;en  cut.  He  would  often  attack 
patients  and  attendants  and  officials  violently.  He  was  wonderfully 
rational  amidst  all  this,  saying  he  could  not  help  it,  that  the  steam  would 
out,  and  that  he  had  no  desire  to  hurt  any  one  or  any  feeling  of  revenge 
against  any  one.  I  have  now  a  lady  who  is  subject  to  paroxysms  of  acute 
mania,  during  which  she  screams  in  an  unearthly  howl,  tears  her  clothes, 
bites  her  own  hands,  and  will  take  your  hand  into  her  mouth  and  bite  it 
a  little  all  round,  without  really  hurting  you,  if  you  will  allow  her. 

The  third  form,  that,  namely,  resulting  from  a  distinct  morbid  impulse 
to  kill  without  conscious  motive,  I  shall  treat  of  more  fiilly  under 
impulsive  insanity,  the  homicidal  variety  of  which  it  is,  with  maniacal 
exaltation  superadded. 

The  fourth,  or  merely  delirious  form,  is  not  really  very  dangerous, 
because  it  is  purposeless  and  aimless,  and  the  violence  is  not  coordinated. 
It  seldom  is  seen  except  when  delirious  patients  are  unduly  controlled. 
A  physician  or  an  attendant  in  an  asylum  generally  walks  up  to  a 


PLATE        VI. 


C  HART 


Showing  the  numbers  per  iOOO  of  Total  admissions, 
and  the  A^es  of  996  cases  of  Mania,  535cases  of  Melancholia, 
and  104  cases  of  General  Paralysis,  making  together  1635  cases 
of  the  1778  Total  cases  admitted  into  the  Royal  Edinburgh 
Asylum    m   Five  years. 


Mania  

Melancholia 

General  Paralysis. 


STATES    OF    MENTAL    EXALTATION.  165 

maniacal  patient  quite  unconcernedly  as  to  danger,  thinking  only  of  the 
symptoms  present  just  as  one  would  go  in  to  see  a  case  of  pneumonia. 

Pkevalence  of  Mania. — The  relative  prevalence  of  conditions  of 
mental  exaltation  is  brought  out  by  the  fact  that  out  of  twenty-three 
hundred  and  seventy-seven  cases  admitted  into  the  Royal  Edinburgh 
xA.sylum  in  the  seven  years,  1874—80,  thirteen  hundred  and  ten,  or  fifty- 
five  per  cent.,  were  classified  as  mania,  while  only  seven  hundred  and 
twenty-nine,  or  thirty-six  per  cent.,  were  cases  of  melancholia.  The 
relative  prevalence  of  the  two  conditions  I  have  shown  in  Plate  VI., 
which  also  shows  the  ages  at  which  they  prevail.  Mental  exaltation  is 
there  seen  to  prevail  more  at  earlier  ages  than  depression,  and  to  occur 
most  at  two  periods,  viz.,  at  the  end  of  adolescence,  and  then  about  ten 
years  afterwards. 

Insane  Delusions  in  Mania. — The  most  important  thing  to  ascertain 
about  delusions  in  mania  is  whether  they  are  "fixed"  or  fleeting. 
A  fixed  delusion  is  usually  the  concentrated  expression  of  a  delusional 
condition  of  mind.  I  mean  that  it  is  seldom  a  patient  merely  believes 
that  a  person  works  an  electric  battery  to  annoy  him.  Such  a  delusion 
is  generally  the  expression  of  an  organic  or  nervous  sensation  of  discom- 
fort or  pain,  which  makes  him  have  his  natural  suspicions  heightened,  he 
being  morbid  on  other  points.  He  will  not  trust  any  one.  He  is  apt  to 
think  the  air  of  his  room  or  his  food  is  poisoned.  If  the  person  whom 
he  believes  to  be  working  this  battery  goes  away,  he  will  soon  fix  in  his 
morbid  imagination  the  same  thing  on  another.  A  patient  usually  not 
only  believes  himself  to  be  a  king,  but  his  whole  state  of  mind  is  that  of 
delusive  grandeur.  Such  fixed  delusional  states,  that  last  for  more  than 
a  few  weeks  in  mania,  are  unfavorable  as  to  prognosis ;  but  do  not  put 
down  either  a  single  delusive  fancy  that  is  repeated  consistently  a  few 
hundred  times,  or  a  delusive  condition  that  merely  lasts  a  few  weeks,  as  a 
fixed  delusion.  The  fixity  of  a  delusion  depends  on  two  things — the 
hold  it  has,  whether  it  dominates  the  mental  life,  including  other  and 
natural  mental  acts ;  and  the  time  it  has  existed.  Fleeting  delusions  are 
most  typically  seen  in  that  delirium  where  nothing  that  is  said  has  any 
relation  to  facts,  and  where  no  fancy  or  untrue  statement  is  ever  repeated 
twice.  In  very  many  cases  of  mania  a  delusion  persists  for  a  few  weeks 
or  longer,  and  yet  passes  away,  and  should  not  be  counted  a  fixed  delu- 
sion. There  is  no  doubt  that  the  less  fixed  and  the  more  fleeting  a 
delusion  is,  the  better  is  the  prognosis. 

Delusions  take  most  various  forms  in  mania.  One  of  the  most  common 
forms  is  mistaking  the  identity  of  persons,  calling  them  by  wrong  names, 
and  recognizing  old  friends  in  persons  never  seen  before.  Certain  kinds 
of  insanity,  such  as  the  puerperal  form,  is  specially  characterized  by  this 
sort  of  delusion. 

Indications  of  Prognosis  in  Mania. — The  following  are  in  my 
experience  favorable  indications  in  prognosis :  A  sudden  onset  of  the 
disease ;  a  short  duration ;  youth  of  the  patient ;  no  fixed  delusions 
or  delusional  conditions  ;  appetite  for  food  not  quite  lost ;  no  positive 
revulsion  against  or  perversions  of  the  food  and  drink  appetites  ;  no  indi- 
cation of  enfeeblement  of  mind ;  no  paralysis  or  paresis,  or  marked 
affection  of  the  pupils ;  no  epileptic  tendency ;  no  complete  obliteration 


166  STATES    OF    MENTAL    EXALTATION. 

or  alteration  of  the  natural  expression  of  the  face  or  eyes ;  the  instincts 
of  delicacy  and  cleanliness  not  quite  lost ;  no  unconsciousness  to  the  calls 
of  nature ;  the  articulation  not  affected ;  the  disease  rising  to  an  acme  and 
then  showing  slow  and  steady  signs  of  receding;  no  former  attacks,  or 
only  one  or  two  that  have  recovered. 

The  effect  of  a  strong  and  direct  hereditary  predisposition  is  not,  as  is 
commonly  believed,  sufficient  to  lessen  the  chances  of  recovery,  especially 
from  the  first  attack.  On  the  contrary,  hereditary  cases  are  often  very 
curable,  but  relapses  are  more  probable.  A  brain  so  predisposed  is  more 
readily  upset  by  slight  causes. 

The  following  are  unfavorable  indications  in  prognosis :  A  gradual  and 
slow  onset,  as  if  it  were  an  evolution  of  an  innate  bad  brain  tendency — 
e.g.,  if  a  naturally  suspicious  man  has  gradually  become  insanely  and 
delusionally  suspicious,  or  a  naturally  vain  man  has  become  affected  with 
insane  delusions  of  grandeur;  great  length  of  duration  of  the  attack, 
especially  after  twelve  months'  persistence  of  fixed  delusions  or  delusional 
states;  extreme  and  increasing  exhaustion  of  the  patient,  in  spite  of 
proper  treatment ;  paralysis  of  the  trophic  power,  so  that  his  body  nutri- 
tion cannot  be  restored;  persistent  refusal  of  food,  requiring  forcible 
feeding ;  extreme  failure  of  the  cardiac  action  and  circulation,  so  that  the 
extremities  are  always  blue  and  cold ;  persistent  affections  of  the  pupils, 
especiallly  extreme  contraction ;  persistently  dirty  habits ;  a  tendency 
towards  dementia ;  a  tendency  towards  chronic  mania ;  an  utter  and  per- 
sistent deterioration  in  the  facial  expression,  especially  if  it  be  towards 
vacuity ;  persistent  and  complete  paralysis  or  perversion  of  the  natural 
affection  and  tastes  and  appetites ;  many  former  attacks ;  convulsive, 
paretic,  paralytic,  or  incoordinative  symptoms  ;  such  perverted  sensations 
as  cause  patients  to  pick  the  skin,  pull  out  the  hair,  bite  off  the  nails  into 
the  quick ;  a  restoration  of  sleep  and  bodily  nutrition,  without  in  due 
time  an  improvement  mentally ;  very  persistent  insane  masturbation  ;  a 
tendency  for  the  exaltation  to  pass  off,  and  fixed  delusion  to  take  its  place ; 
excitation  of  the  limbs  and  subsultus  tendinum  ;  a  "  typhoid  "  condition. 

Termination  of  Mania. — There  may  be  said  to  be  five  usual  termi- 
nations. 1.  Complete  recovery ;  this  takes  place  in  fifty-four  per  cent, 
of  all  the  cases  of  mania.  2.  Partial  recovery;  the  patient  becoming 
rational  and  fit  for  work,  but  where  there  is  a  change  of  character  or 
affection,  or  there  is  an  eccentricity,  or  slight  mental  weakness,  or  want 
of  mental  inhibition,  or  lack  of  fixity  of  purpose,  or  a  partial  paralysis  of 
the  social  instincts,  or  some  inability  to  get  on  with  people,  or  a  lack  or 
lessening  of  some  mental  quality  which  the  patient  possessed  before. 
This  is  unfortunately  a  by  no  means  uncommon  result  of  an  attack  of  any 
kind  of  insanity,  but  more  especially  of  an  attack  of  mania.  Such 
persons  count,  of  course,  among  the  recoveries,  and  are  reckoned  legally 
sane.  It  is  quite  impossible  to  find  out  how  many  such  cases  there  are, 
but  I  fear  that  at  least  one-third  of  all  those  who  "  recover  "  exhibit  some 
such  mental  change  as  compared  with  their  foimer  sane  selves.  I  think 
it  is  of  the  utmost  importance  to  have  the  cure  completed  therefore,  if 
possible,  by  prolonged  medical  care,  by  getting  the  whole  bodily  state,  in 
regard  to  nutrition  and  nourishment,  up  to  the  highest  possible  mark 
before  a  patient  returns  to  work  or  subjects  himself  to  the  causes  of  a 


STATES    OF    MENTAL    EXALTATION.  167 

relapse.  It  is  the  existence  of  this  condition  of  mental  change  or  mental 
twist  so  often,  and  the  liability  to  relapse,  that  make  the  public  suspi- 
cious of  a  man  who  has  been  insane ;  through  which  suspicion  great  hard- 
ship and  injustice  are  often  done  to  those  who  have  already  suffered  from 
one  of  the  most  terrible  of  human  diseases.  3.  The  substitution  of  fixed 
delusions  or  delusional  states  (monomania)  for  the  exaltation  as  the  latter 
passes  off.  It  is  difficult  to  find  out  statistically  how  often  this  occurs. 
The  patients  may  live  long  when  this  takes  place,  except  the  delusional 
condition  be  that  of  morbid  suspicion,  in  which  case  they  will  probably 
die  of  phthisis  within  a  few  years.  4.  Dementia  supervenes.  This 
happens  in  about  thirty  per  cent,  of  the  cases  of  mania  generally.  It  is 
the  event  we  most  dread.  It  is  equivalent  to  a  mental  death,  while  the 
body  may  live  for  many  years,  especially  if  the  dementia  has  come  on  in 
youth.  We  have  had  many  patients  live  so  for  fifty  years  in  Morning- 
side.  The  bulk  of  the  chronic  patients  in  asylums  are  of  this  class.  5. 
Death  occurs  in  about  five  per  cent,  of  the  cases  from  exhaustion,  or  from 
causes  directly  traceable  to  the  disease. 

It  must  be  understood  that  those  are  the  terminations  in  cases  of  mania 
so  severe  as  to  require  asylum  treatment.  If  Ave  could  include  the  slighter 
cases  treated  at  home,  the  recoveries  would  be  more  and  the  terminations 
in  dementia  and  death  fewer. 

Prophylaxis  of  Mania. — A  very  important  question  often  needs  solu- 
tion by  medical  men  in  practice.  There  are  young  people  growing  up  in 
the  families  they  advise  and  attend  with  neurotic  heredity,  manifestly 
unstable  brain  constitution,  "  excitable "  dispositions  and  nervous  dia- 
thesis ;  and  the  all-important  question  is  asked.  How  can  such  persons 
best  avoid  the  tendency  to  attacks  of  mania  ?  They  have  patients  who 
have  already  had  attacks  of  maniacal  exaltation,  some  decided  and  some 
only  nascent.  How  can  such  be  avoided  in  the  future  ?  If  our  present 
knowledge  enabled  us  to  answer  these  questions,  no  doubt  there  would 
be  less  insanity  in  the  world  than  there  is.  We  cannot  do  so  surely,  but 
we  can  do  something  in  the  direction  of  lessening  the  tendency  of  a  brain 
to  mania,  I  have  no  doubt.  Beyond  question,  persons  with  this  brain 
constitution  should  not  enter  on  exciting  and  hazardous  occupations.  To 
take  extreme  examples,  they  should  not  be  stockbrokers,  election  agents, 
or  speculators.  Quiet  routine  modes  of  life  suit  them  best ;  positions 
with  fixed  work  and  fixed  salaries  are  most  desirable  for  them.  Much 
outdoor  life,  living  according  to  rule,  dividing  up  their  day  into  regular 
portions  for  work  and  idleness  and  amusement. 

As  regards  diet,  the  same  advice  I  gave  about  children  predisposed  to 
melancholia  applies  here.  It  should  consist  largely  of  milk  and  fiirina- 
ceous  diet  for  the  young.  I  lately  saw  a  most  excitable  boy  of  six,  very 
thin,  restless,  not  sleeping  much,  and,  of  course,  very  bright  and  quick 
for  his  age.  I  found  he  was  getting  animal  food  three  times  a  day,  and 
his  guardians  deplored  the  fact  that  he  could  not  take  milk ;  my  advice 
was  to  starve  him  into  taking  it,  to  make  him  walk  much  and  keep  him 
out,  and  give  him  when  he  came  in  only  bread  and  milk.  Of  course,  it 
was  disagreeable  at  first,  but  the  boy  soon  acquired  an  appetite  for  such 
food,  his  bodily  conformation  largely  changed,  and  he  got  fatter,  less 
active,  and  slept  far  more.     Children  with  this  disposition  are  nearly 


168  STATES    OF    MENTAL    EXALTATION. 

always  flesh-eaters,  and  I  have  sometimes  found  them  fed  on  beefsteaks 
and  port  "wine,  with  strong  beef-tea  between  meals!  I  look  on  strong 
beef-tea  drunk  alone,  without  bread  or  potatoes,  as  simple  poison  for  such 
children.  I  do  not,  of  course,  mean  this  to  apply  when  they  are  ill,  and 
need  a  stimulant.  Such  persons  should  take  as  much  sleep  as  possible; 
they  should  cultivate  quiet  hobbies  ;  they  should  select  country  occupa- 
tions, and  avoid  stimulants,  tobacco,  and  sexual  intercourse  till  after 
adolescence.  While  ordinary  well-constituted  brains  may  stand  excesses 
of  all  kinds,  in  work  and  in  pleasure,  and  may  even  in  a  way  be  said  to 
be  sometimes  the  better  for  them,  this  is  unquestionably  not  the  case 
with  those  I  am  now  describing.  The  excess  of  power  beyond  the  daily 
needs,  the  capacity  of  quick  recuperation,  the  tendency  to  stop  working 
and  to  sleep  when  tired,  the  power  of  being  satisfied  with  only  a  slight  or 
an  occasional  excess  over  what  the  strict  laws  of  nature  would  dictate, 
which  characterize  healthy  well-constituted  brains,  are  all  wanting  in 
those  predisposed  to  maniacal  attacks.  I  cannot  help  thinking  that  for 
such  persons  to  take  to  study  or  to  occupations  that  imply  much  brain- 
work  is  a  risk,  though  they  have  often  bright  intellects.  It  seems  to  me 
as  if  instead  of  that  they  should  go  back  to  nature  and  mother  earth,  and 
become  farmers  and  colonists.  I  once  knew  two  brothers,  twins,  alike  in 
mind  and  body,  who  had  a  strong  heredity  to  mania.  They  both 
became  medical  students,  and  one  had  an  attack  of  acute  mania  at  twenty, 
which  ended  in  dementia.  At  the  beginning  of  his  brother's  attack  the 
other  had  distinct  premonitions  of  the  same  disease — was  sleepless, 
restless,  unsettled,  had  queer  sensations  in  his  head,  and  felt  as  if  he 
would  lose  his  self-control.  But  he  at  once  fled,  as  for  his  life,  from 
books  and  brain-work,  and  went  to  be  a  land-surveyor  in  the  Far  West. 
His  neurotic  symptoms  passed  off",  and  he  grew  into  a  strong  and  happy 
man.  I  think  it  is  the  instinct  of  self-preservation  that  makes  young 
men  sometimes  fly  from  the  influences  of  civilization  and  take  to  the 
backwoods.  But  what  about  the  young  women  ?  Alas  !  the  prospect 
for  those  with  such  heredity,  and  when  they  are  well  off"  and  live  in 
cities,  is  often  lamentable.  So  far  as  my  experience  and  observation 
go,  the  regulated  life  of  a  convent  or  sisterhood,  or  systematic  religious 
and  philanthropic  work,  fulfils  the  conditions  of  prophylaxis  when  the 
tendency  is  very  strong,  better  than  anything  else.  I  am  often  profoundly 
impressed  with  the  physiological  and  medico-psychological  character 
of  many  of  the  observances  and  regulations  of  the  Roman  Catholic 
Church  as  to  modes  of  life  and  outlets  for  the  emotions.  The  framers  of 
these  observances  had  often  anticipated  modern  physiological  inductions. 
But  suppose  there  is  not  merely  a  predisposition,  but  that  the  actual 
prodromata  of  the  disease  are  showing  themselves,  let  us  say  sleeplessness, 
want  of  full  power  of  self-control,  and  general  unsettledness,  should 
medicinal  hypnotics  be  taken — opium,  or  bromides,  or  chloral,  or 
henbane  ?  I  think  I  have  seen  these  do  more  good  as  sleep-producing 
prophylactics  than  as  curatives  after  the  disease  had  actually  begun. 
There  is  no  doubt  that  in  the  matter  of  its  rest-in-sleep  power,  like  many 
of  its  other  faculties,  the  brain  forms  habits,  and  gets  into  bad  and  morbid 
as  well  as  into  good  habits.     A  man  falls  off"  his  sleep  at  his  regular 


STATES    OF    MENTAL    EXALTATION.  169 

time  or  awakes  at  too  early  an  hour,  and  he  cannot  get  rid  of  this  habit 
his  brain  has  got  or  is  getting  into,  and  if  allowed  to  go  on  uncorrected 
he  will  become  exhausted  and  insane.  Now,  while  I  should  in  such 
a  case  invariably  try  first  nature's  simple  sedatives — sea  or  mountain  air 
breathed  all  day,  muscular  fatigue,  hot  drinks  at  bedtime,  change  of 
scene  and  work,  etc. ;  yet  I  have  to  aid  these  often  by  a  few  doses 
of  chloral  and  the  bromides,  or  by  a  grain  or  two  of  opium  at  night. 
Camphor  and  tincture  of  lupuline  are  often  sufiicient  sedatives,  or  a  few 
drops  of  tincture  of  belladonna,  in  fact  any  sleep-producer;  but  do  not, 
if  possible,  let  the  brain  get  into  the  evil  habit  of  depending  on  such 
drugs  for  sleep. 


LECTURE    V. 

STATES  OF  ALTERNATION,  PERIODICITY,  AND  RELAPSE  IN 
MENTAL  DISEASES  {FOLIE  CIRCULAIRE,  PSYCHORVTHM,  FOLIE 
A  DOUBLE  FORME,  CIRCULAR  INSANITY,  PERIODIC  MANIA, 
RECURRENT  MANIA,  KATATONIA). 

One  of  the  most  fundamental  of  the  laws  that  govern  the  higher 
functions  of  the  nervous  centres  in  all  vertebrates  is  that  of  alternation 
and  periodicity  of  activity  and  inactivity.  In  all  the  higher  species  of 
the  class  the  periods  of  inactivity  are  marked  by  unconsciousness,  and 
are  often  combined  with  the  mental  phenomena  of  dreaming  and  muscular 
expressions  or  equivalents  of  ideation;  which  things  are  quite  as  strange 
and  inexplicable  in  their  essential  nature  as  the  phenomena  of  mental 
disease.  Both  may  be  in  a  general  way  understood  by  reference  to  men- 
talization  as  a  brain  function.  Neither  are  in  any  way  comprehensible 
on  any  mere  mind  theory  apart  from  brain.  The  sleep  and  waking 
periodicity  of  the  higher  brain  functions  is  the  foundation  and  type  of 
all  the  other  periodicities  which  exist  in  the  nervous  functions,  and  they 
are  not  a  few.  The  yearly  hibernation  of  many  animals,  the  daily 
periodic  rises  and  falls  of  body  temperature,  the  daily  increase  and 
decrease  of  the  pulsations  of  the  heart  and  of  the  cardiac  pressure,  the 
periodic  returns  of  the  appetites  for  food  and  drink,  and  of  the  activities 
of  the  glands  and  involuntary  muscles  through  which  food  is  digested  and 
assimilated,  are  all  examples  of  secondary  nervous  periodicities  which 
occur  in  the  course  of  the  daily  life  of  the  organism.  When  we  look  at 
the  function  of  reproduction  of  the  organism,  we  find  that  every  activity 
and  process  is  subject  to  laws  of  periodicity  of  the  most  marked  character ; 
and  there  can  be  no  doubt  that  these  all  have  their  origin  in  the  brain. 
The  period  of  reproductive  activity  is  always,  in  both  sexes,  the  period 
of  greatest  physiological  mental  exaltation.  The  periodic  rutting  season 
in  male  animals,  with  its  courage,  pride,  activity,  display,  pugnacity,  and 
restlessness ;  the  young-bearing  and  suckling  period  in  females,  with  its 
increased  courage,  skill,  cunning,  protective  and  providing  instincts,  show 
how  the  functions  of  the  brain  are  affected  by  the  reproductive  perio- 
dicity. So  much  are  they  affected  that  the  mental  characteristics  of  some 
animals  are  completely  changed  from  their  natural  condition  and  reversed, 
the  timid  becoming  bold  and  the  shy  obtrusive ;  hereditary  and  natural 
antipathies  and  fears  disappear  for  the  time,  the  habits  change,  night- 
feeders  become  day-feeders,  etc.  We  should  not  approach  the  study  of 
the  periodicity  of  symptoms  in  nervous  and  niental  diseases  without 
keeping  in  mind  these  laws  and  facts  of  the  physiological  periodicity  of 
normal  nerve  function  wherever  we  have  a  higher  nervous  system. 

Looking  at  the  mental  activities  of  human   beings,   we   find   them 


STATES    OF    MENTAL    ALTERNATION.  171 

strongly  influenced  by  the  physiological  periodicities.  What  man  is  there 
who  is  not  emotionally  more  elevated  or  depressed,  more  active  or  inac- 
tive in  mind,  at  certain  times,  or  at  his  periods  of  almost  regularly  re- 
curring reproductive  desire  and  capacity  ?  What  woman  is  exactly  the 
same  in  mind  before,  during,  and  after  menstruation,  and  during  preg- 
nancy or  lactation  ?  And  the  instant  we  pass  from  absolutely  healthy 
brains,  all  those  periodicities  count  for  more  in  the  mental  life,  their 
effect  in  dulling,  elevating,  and  depressing  being  far  greater.  There  are 
thousands  of  sane  men  and  women  who  are  regularly  duller  in  the  morn- 
ing and  more  lively  in  the  evening,  or  the  reverse ;  or  who  are  duller  in 
the  winter  and  more  elevated  in  the  summer ;  or  who  are  more  irritable — 
that  is,  have  diminished  inhibitory  power — at  periodic  intervals,  or  who 
are  subject  to  "moods"  and  "tempers"  periodically.  There  are  many 
persons  whose  mental  life  is  one  long  alternation  of  "action"  and  "re- 
action," activity  and  torpor,  by  a  natural  law  of  their  organization. 
When  we  look  at  diseases  of  the  nervous  system  other  than  the  mental, 
we  find  that  many  of  them  are  often  markedly  periodic  in  their  symptoms 
and  times  of  recurrence.  I  need  only  instance  neuralgia,  migraine,  and, 
above  all,  epilepsy,  that  motor  analogue  of  many  mental  diseases. 

Two  French  writers,  Falret  and  Baillarger,  were  the  first  to  describe 
as  a  special  form  of  insanity -certain  cases  in  which  there  are  regularly 
alternating  and  recurring  periods  of  mental  exaltation,  depression,  and 
sanity,  and  to  call  it  folie  circulaire.  Each  of  these  periods  may  vary 
in  absolute  duration  from  a  day  to  several  years,  and  in  relative  duration 
to  the  other  conditions  in  the  circuit  in  different  cases ;  but  they  always 
recur  and  follow  each  other  with  more  or  less  regularity.  In  some  the 
period  of  exaltation  is  long  and  the  depression  and  sanity  short ;  in 
others  this  is  reversed.  But  in  the  really  typical  case  the  periods  are 
each  about  the  same  length  in  each  psychological  circle,  and  the  recur- 
ring circles  all  about  the  same  size.  Usually  there  is  something  special 
about  the  exaltation  and  depression.  The  exaltation  is  very  pure  brain 
exaltation,  with  often  hypersesthesia  and  exaltation  of  many  of  the  ner- 
vous functions,  with  much  reasoning  power  left,  but  little  self-control  or 
common  sense ;  the  condition  described  by  the  French  as  folie  raisson- 
nante,  or  Pritchard's  moral  insanity,  being  well  marked  at  the  early 
stage.  There  is  in  nearly  all  the  cases  great  increase  of  the  reproduc- 
tive nisus.  The  phases  of  the  exaltation,  down  even  to  small  things, 
recur  regularly  in  different  attacks  at  the  same  time.  The  depression  is 
apt  to  be  characterized  by  apathy  and  torpor  rather  than  by  intense 
mental  pain :  there  are  seldom  any  strong  suicidal  feelings  or  impulses. 
And  the  period  of  sanity  is  apt  to  be  a  sort  of  stupid,  inactive  sanity, 
wanting  in  volitional  power,  full  affectiveness,  and  spontaneity.  The 
mental  balance  goes  on  oscillating  between  melancholia  and  mania, 
standing  still  at  the  happy  mean  of  apparent  sanity  just  long  enough  to 
raise  hopes  that  recovery  has  taken  place  for  a  few  times,  till  the  nature 
of  the  disease  is  apparent  to  the  physician,  and  as  often  as  they  occur  to 
ever-hoping  relatives.  It  is  mostly  an  incurable  disease,  and  the  bad 
cases  are  usually  sent  to  asylums  rather  than  treated  at  home. 

The  interest  of  this  form  of  mental  disease  is  small  when  it  is  merely 
looked  at  as  a  rare  psychosis  of  typical  form ;  but  it  is  very  great  indeed 


172  STATES    OF    MENTAL    ALTERNATION. 

to  the  student  of  psychiatry  when,  in  the  first  phace,  we  make  it  a  means 
of  studying  the  clinical  differences  in  the  whole  brain  and  body  state  of 
the  same  patient  in  exaltation,  depression,  and  sanity  respectively ;  and 
when,  in  the  second  place,  we  look  on  it  as  a  pathological  illustration  of 
the  great  physiological  periodicities  to  which  I  have  referred,  and  of  the 
almost  constant  tendency  there  is  in  nearly  all  cases  of  insanity,  or  at 
least  in  most  of  those  that  are  hereditary,  towards  relapse,  alternation, 
periodicity,  or  sympathy  with  exalted  physiological  function. 

The  following  are  some  illustrative  cases  : 

D.  A.,  set.  49  on  admission  to  asylum.  He  had  never  been  placed  in 
a  hospital  for  the  insane  before,  though  he  had  had  from  his  boyhood 
dull  times  and  active  times,  and  many  slighter  attacks  of  the  kind  I  am 
about  to  describe  for  five  or  six  years  previous  to  his  admission.  In  one 
of  the  periods  of  exaltation,  while  holding  an  important  position  in  India, 
he  had  got  two  tiger  cubs,  and  tried  to  drive  them  in  harness  through  the 
streets  of  the  Residency.  His  education  was  good,  his  temperament 
sanguine.  He  had  been  reckoned  proud  and  retiring,  and  he  was  of  an 
old  and  distinguished  family.  In  bodily  conformation,  carriage,  and 
bearing  he  was  the  type  of  an  aristocrat.  A  paternal  uncle,  at  least, 
had  been  insane,  and  had  shown  periodicity.  His  family  had  been  a 
very  artistic  one,  but  he  had  never,  when  sane,  shown  any  talent  in  that 
way.     He  had  married  and  had  children. 

Just  before  admission  he  had  been  spending  money  recklessly,  pro- 
posing marriage  to  many  suitable  and  unsuitable  persons,  getting  into 
passions  and  using  threats  about  trifles,  reckless,  eccentric,  changeful  as 
the  winds  in  intention  and  execution.  The  attack  was  coming  on,  but 
had  not  come  to  a  height  till  a  week  after  a  domestic  loss. 

When  admitted  he  was  much  excited  and  very  indignant,  calling  on 
all  to  witness  that  he  was  illegally  imprisoned,  threatening  the  dire 
vengeance  of  the  law  on  all  who  had  to  do  with  it,  but  in  about  ten  min- 
utes he  was  quite  jolly,  and  amusing  himself  with  a  game  of  billiards. 
At  first  he  was  exalted  mentally,  but  had  much  self-control.  His  ex- 
citement consisted  in  a  constant  restlessness,  a  perpetual  twisting  move- 
ment and  play  of  his  facial  muscles.  He  could  not  sit  still,  or  read,  or 
engage  in  a  game  for  long.  He  talked  much,  but  could  not  stick  to  one 
subject ;  he  was  boastful  in  a  way  that  was  to  him  unnatural ;  he  spoke 
of  his  private  affairs,  and  would  indulge  in  very  pointed  questions  and 
remarks,  without  much  regard  to  your  feelings.  To  a  good  billiard- 
player,  "  I'll  give  you  fifty  points,  and  bet  a  pair  of  gloves  I'll  beat  you. 
I  don't  want  to  hurt  your  feelings,  but  I  suppose  you  know  your  style  of 
play  is  not  very  fine."     To  a  man  who  had  been  in  trade,  "What  do  you 

think  of  my  stockings,  Mr. ?     That  was  in  your  line."     He  was 

often  extremely  amusing,  fluent,  and  witty,  which  he  had  never  been 
when  well.  He  would  rattle  off  Scotch  to  the  pauper  patients  in  the 
grounds,  French  to  the  ladies,  and  Hisdustani  to  himself  in  a  way  he 
could  never  do  when  sane.  In  dress  he  was  untidy,  and  in  habits  dirty. 
To  the  ladies,  of  whose  society  he  was  extremely  fond,  he  was  exagger- 
atedly polite,  with  the  grand  air  of  the  olden  time ;  but  if  they  gave  him 
any  encouragement  he  would  soon  become  too  familiar.  He  was  always 
giving  them  flowers,  which  he  had  stolen,  and  writing  them  notes,  or 


STATES    OF    MENTAL    ALTERNATION.  173 

trying  to  kiss  the  maid-servants.  If  he  had  any  request  to  make  from  a 
lady  in  the  drawing-room,  it  was  no  uncommon  thing  for  him  to  go  down 
on  one  knee,  with  his  hand  to  his  heart,  and  all  this  done  most  gracefully 
and  amusingly,  as  if  half  in  fun  and  much  in  earnest. 

He  smoked  as  much  as  he  could  get,  and  was  always  grumbling  he  did 
not  get  cigars  and  tobacco  enough,  and  begging,  borrowing,  or  stealing 
more.  He  ate  enormously,  but  not  nicely,  of  everything  that  came  in 
his  Avay.  He  picked  up  and  appropriated  everything  belonging  to  others 
that  he  had  a  fancy  for,  and  did  this  also  most  gracefully,  as  if  it  was 
the  most  natural  thing  in  the  world.  He  was  irritable  when  controlled, 
contradicted,  or  refused  requests,  and  he  was  always  making  innumerable 
and  impossible  requests.  He  slept  badly,  and  would,  if  allowed,  sit  up 
all  night,  or  get  up  and  move  about  by  three  or  four  o'clock  in  the 
morning.  He  was  not  susceptible  to  cold,  sitting  with  all  his  windows 
open  in  Avinter. 

He  passed  gradually  out  of  one  stage  into  another.  The  next  stage 
was  a  more  maniacal  one.  He  dressed  more  grotesquely,  and  always 
wanted  to  put  on  three  or  four  coats,  vests,  or  trousers  on  the  top  of  each 
other.  He  Avould  come  in  to  a  dance  with  four  vests,  would  go  behind  a 
door  or  another  man.  and  slip  one  and  then  another  off  as  he  got  warm. 
His  habits  and  ways  got  more  dirty  and  disorderly.  His  irritability  took 
violent  forms,  assaulting  his  attendants,  smashing  furniture,  etc.  His 
conduct  became  so  uncontrolled  that  he  could  not  go  to  the  drawing-room 
or  to  church.  He  would  run  after  a  petticoat  without  regard  to  the  ap- 
pearance or  age  of  its  wearer.  His  whole  tastes  as  to  food  were  the  op- 
posite to  what  they  Avere  in  health.  He  liked  porridge,  which  he 
could  not  abide  when  Avell,  and  if  he  did  not  feel  inclined  to  take  it,  he 
Avould  turn  it  out  on  to  his  neAvspaper,  put  it  in  his  pocket,  and  eat  it 
when  he  felt  hungry.  He  would  mix  up  soup,  milk,  and  claret,  and  eat 
them  together.  Scarcely  anything  was  incongruous  or  disgusting  to  him. 
He  Avore  his  hair  very  short,  and  Avould  singe  it  or  cut  it  himself  if  he 
could  get  no  one  else  to  do  it.  He  would,  in  playing  cricket,  strip  him- 
self almost  naked,  or  put  on  the  most  ridiculous  things,  a  Avoman's  hat 
or  shawl,  or  a  cap  turned  outside  in.  He  turned  up  at  morning  prayers 
one  day  in  buckskin  tights,  a  red  vest,  a  blue  cap,  and  black  SAvallow-tail. 
His  boAvels  Avere  ahvays  moved  tAvice  or  thrice  a  day.  During  all  this 
time  he  was  losing  or  tending  to  lose  Aveight  is  spite  of  all  he  ate.  He 
had  his  better  and  Avorse  days  all  through,  usually  in  alternation.  He 
used  to  paint  and  draw  pictures  and  portraits  at  this  stage,  producing 
the  vilest  daubs,  spitting  on  the  paper  to  moisten  his  colors,  and  using 
his  hand  and  fingers  to  spread  his  paints.  These  he  would  carry  in  his 
pocket  by  the  dozen,  shoAving  them  to  any  one  he  met — and  he  could 
pass  no  one  Avithout  speaking.  He  said  he  had  never  known  he  could 
paint  before.  So  with  singing  :  he  would  sing  in  discord,  and  think  he 
was  doing  splendidly.  Yet  Avith  all  this  there  never  left  him  a  certain 
jauntiness  and  grace  of  manner.  No  one,  at  his  worst,  could  have  taken 
him  for  anybody  but  a  high-bred  gentleman. 

As  this  brain  exaltation  came  on  and  increased  in  every  successive 
attack,  each  little  phase,  each  little  morbid  way,  such  as  smoking,  eating 
certain  kinds  of  food,  cutting  or  singeing  his  hair  and  beard,  painting, 


174  STATES    OF    MENTAL    ALTERNATION. 

putting  on  one  coat  on  the  top  of  another,  would  recur  with  the  regu- 
larity of  the  bud,  leaf,  and  fruit  of  a  tree. 

The  next  stage  was  the  gradual  subsidence  of  all  these  symptoms  of 
maniacal  exaltation,  and  a  resumption  of  his  former  habits  and  ways  and 
appearance. 

The  first  stage,  corresponding  to  simple  mania,  lasted  for  about  a 
month ;  the  second,  with  the  symptoms  of  mild  acute  mania,  about  two 
months,  and  his  recovering  stage  about  three  months,  so  that  the  whole 
period  of  exaltation  lasted  six  months ;  but  he  did  not  stop  at  the  sane 
stage.  He  at  once  passed  into  a  condition  of  great  mental  depression. 
To  see  him  in  that,  one  would  scarcely  have  known  him  to  be  the  same 
man.  His  hair  well  grown,  his  whiskers  trim,  his  features  and  eyes  dull 
and  inexpressive,  his  dress  most  scrupulous  and  neat,  his  manner  distant 
and  nervous ;  in  speech  reticent,  and  never  venturing  a  remark  ;  in  feel- 
ing depressed,  fearful,  and  unreliant.  He  thought  he  was  so  wicked 
that  he  should  not  see  any  one.  He  now  disliked  most  of  the  people  he 
had  cultivated  during  his  exaltation,  especially  relying  on  the  chief  at- 
tendant, who  had  controlled  him  most,  and  whom  he  had  most  heartily 
abused.  His  habits  were  sedentary,  he  could  scarcely  be  got  to  go  for  a 
walk ;  his  appetite  was  now  moderate,  and  his  tastes  very  particular,  not 
being  able  to  bear  the  smell  of  tobacco  or  to  look  at  porridge  or  messes 
of  any  kind,  and  most  sensitive  to  dirt  and  bad  smells.  He  became  very 
penurious  about  money.  He  was  always  thinking  he  was  doing  wrong 
or  giving  offence,  and  did  not  like  company,  while  he  was  most  moral 
and  religious  in  his  feelings  and  habits.  His  whole  intellectual  and  aflfec- 
tive  life  was  far  more  unlike  his  exalted  self  than  one  average  man  is 
unlike  another.  He  was  stationary  in  weight  at  first,  but  soon  began  to 
gain.  He  was  most  sensitive  to  cold  and  draughts  and  loud  noises,  in  all 
of  which  he  had  delighted  before.  He  was  full  of  a  morbid  sorrow  and 
regret  for  his  previous  conduct ;  but  he  was  morbidly  suspicious  at  this 
stage,  and  used  to  think  that  the  things  he  had  given  away  or  destroyed 
during  his  excitement  had  been  stolen.  This  condition  lasted  for  about 
three  months,  gradually  passing  into  one  of  complete  sanity,  without  de- 
pression or  elevation,  but  with  some  inertness  at  first,  and  without  much 
capacity  for  business.  This  lasted  about  six  months,  and  then  the  signs 
of  elevation  again  began.  Altogether  this  circle  of  elevation,  depression, 
and  sanity  lasted  about  fifteen  months.  There  was  no  marked  line  any- 
where, though  the  most  distinct  and  sudden  transition  was  between  the 
elevation  and  the  depression. 

The  development  of  the  exaltation  next  time  was  a  slow  process,  taking 
about  two  months  before  it  got  so  bad  that  he  had  to  come  back  to  the 
asylum.  The  sort  of  things  he  did  were  going  out  to  ride  at  10  o'clock  p.m., 
never  going  to  bed,  smoking  all  the  time,  foolishly  wasting  his  money, 
proposing  to  marry  ladies  and  women  suitable  and  unsuitable,  sometimes 
two  in  a  day,  telling  one,  as  an  inducement  to  accept  him,  that  if  she 
would  marry  him  she  could  put  him  into  an  asylum  and  enjoy  his  pen- 
sion !  He  went  into  a  shop  to  buy  a  pair  of  gloves,  and  the  shop-girl 
taking  his  fancy,  he  went  down  on  his  knees  to  her,  telling  her  he  had 
fallen  in  love  with  her.  His  nisus  generativus  was  always  exalted  during 
the  excitement,  but  seldom  assumed  very  gross  forms.     He  often  said 


STATEvS    OF    MENTAL    ALTERNATION.  175 

that  if  he  could  be  castrated  he  would  be  cured.  The  great  difficulty  at 
this  stage  was  to  get  "  facts  "  indicating  insanity  to  put  in  the  medical 
certificates  for  his  admission  to  an  asylum,  for  he  was  very  acute,  and 
knew  what  a  doctor's  visit  meant  quite  well ! 

In  the  second  circle  of  his  disease  after  coming  to  the  asylum,  all  the 
symptoms  were  similar  to  the  first,  and  developed  themselves  in  the  same 
order.  The  excitement  was  more  acutely  maniacal  than  it  ever  was  before 
or  has  been  since.  The  whole  period  of  elevation  lasted  a  year  this  time, 
of  depression  six  months,  and  sanity  six  months,  the  circle  taking  two 
years  to  get  through. 

The  third  circle  had  a  period  of  excitement  of  ten  months,  of  depres- 
sion of  six  months,  and  of  eight  months  of  sanity- — in  all,  two  years. 
The  fourth  circle  had  a  period  of  excitement  of  thirteen  months,  of  de- 
pression of  about  six  months,  and  of  sanity  of  fourteen  months — in  all, 
two  years  and  nine  months.  He  was  out  of  the  asylum,  living  at  home, 
for  a  year  and  eight  months  during  part  of  the  depression,  the  whole 
period  of  sanity,  and  the  first  month  of  the  commencement  of  the  ex- 
citement. He  did  not  enjoy  the  society  of  his  relations  during  the  de- 
pression, and  they  said  he  would  have  been  better  to  have  been  in  the 
asylum ;  and  at  the  beginning  of  the  excitement,  when  they  had  to  re- 
monstrate with  or  control  him,  his  affection  for  them  ceased,  and  he  got 
on  worse  with  them  than  in  the  asylum  with  strangers.  He  said  cruel 
and  unkind  things  to  them. 

In  the  fifth  alternation  the  excitement  lasted  two  years,  the  depression 
twelve  months,  and  the  sanity  fifteen  months — the  whole  thus  taking  four 
years  and  three  months.  He  is  now  in  the  twenty-third  month  of  the 
exalted  stage  of  the  sixth  circle,  with  the  usual  symptoms,  but  none  of 
them  are  so  severe  as  they  were  on  previous  occasions.  It  seems  as  if, 
at  sixty-two,  his  brain  was  not  capable  of  taking  on  so  acute  an  attack 
of  excitement,  the  nisus  generativus  not  being  so  keen.  He  is  now 
capable  of  being  sooner  tired,  and  takes  rest,  which  he  never  did  before, 
and  the  diurnal  changes  are  very  marked.  He  has  one  good  and  then  a 
bad  day.  But  the  outward  eroticism,  the  alertness  and  grace  of  move- 
ment, the  kleptomaniacal  tendencies,  and  all  the  small  phases  of  his  ex- 
altation are  still  there,  there  being  no  trace  of  the  mental  enfeeblement 
of  dementia,  of  bodily  exhaustion,  or  of  chronic  mania.  The  damage 
done  to  the  organ  by  the  previous  attacks  of  exalted  morbid  energizing 
has  evidently  been  repaired  in  the  intervals  of  sanity,  during  which  he 
lays  on  flesh  greatly.  The  bromide  of  potassium  alone  and  combined 
with  cannabis  indica  did  not  influence  any  of  the  attacks  of  excitement. 

The  following  is  the  record  of  a  case  of  most  prolonged,  and,  on  the 
whole,  one  of  the  most  regularly  alternating  cases  of  foUe  circulaire  in 
short  circles  I  have  ever  seen: 

D.  B.,  get.  30,  was  admitted  to  the  Royal  Edinburgh  Asylum  in  1847 
without  any  history  whatever ;  but  she  was  a  person  of  education  and 
intelligence,  though  sent  as  a  pauper  patient.  She  labored  under  all  the 
symptoms  of  acute  mania  at  first,  and  in  a  few  days  it  was  recorded  that 
she  was  "imbecile,"  then  in  a  few  days  more  that  she  was  quite  well. 
Since  that  time  till  now — for  thirty-six  years — she  has  had  regularly 
recurring  short  attacks  of  acute  mania,  during  which  she  is  restless, 


176  STATES    OF    MENTAL    ALTERNATION. 

incoherent,  excited,  destructive  to  her  clothing,  violent,  and  with  no 
memory  or  consciousness  of  familiar  things  or  persons,  this  lasting  from 
a  week  to  four  weeks  usually.  This  is  succeeded  by  a  few  days  of  a  con- 
dition with  all  the  symptoms  of  dementia  with  a  little  depression,  and  she 
then  becomes  practically  sane  for  a  period  of  from  a  fortnight  to  eight 
weeks.  Her  circle  takes  from  four  to  twelve  weeks  to  complete,  enfeeble- 
ment  of  mind  taking  the  place  of  the  more  usual  depression.  We  have 
a.  wonderfully  complete  record  of  her  symptoms  all  these  thirty-five  years ; 
and  though  once  or  twice  there  are  such  entries  as  "  She  is  now  almost 
continuously  excited,"  as  in  1852  for  a  month  or  so,  or  "Periods  of 
excitement  more  frequent,  of  quiet  shorter,"  as  in  1853  and  in  1861, 
"Intervals  of  quiet  longer,"  as  in  1862,  yet  the  irregularities  are  no 
greater  than  are  common  in  regard  to  menstruation  in  the  average 
woman.  There  can  be  no  doubt  that  this  is  an  example  of  mental 
alternations  governed  in  their  times  of  occurrence  and  duration  by  the 
menstrual  periodicity.  For  long  she  had  amenorrhoea,  but  the  return  of 
the  catamenia  made  no  difference,  and,  more  strange,  the  ceasing  of  men- 
struation at  the  climacteric  made  no  difference.  Now,  at  sixty-six,  the 
regular  alternations  of  acute  exaltation,  mild  stupor,  and  sanity  are  not 
so  regular  as  before,  and  the  symptoms  of  the  exaltation  are  scarcely  so 
acutely  maniacal  as  at  first.  The  whole  case  is  otherwise  instructive,  for 
though  it  shows  the  known  tendency  in  a  brain  for  acute  excitement  to 
exhaust  and  destroy  the  normal  power  of  energizing  of  the  convolutions 
and  leave  that  diseased  mentalization  which  we  call  dementia,  it  also 
shows  this,  that  even  severe  attacks,  when  short,  produce  only  a  short 
enfeeblement,  which  is  recovered  from  soon.  Most  instructively  of  all,  it 
shows  that  over  two  hundred  of  such  attacks,  continued  for  such  an 
enormously  long  period  as  thirty-six  years,  need  not  necessarily  destroy 
the  mental  power  of  the  brain  and  produce  complete  and  permanent 
dementia.  The  brain  in  this  proves  the  recuperative  and  resistive  power 
that  it  shows  in  many  other  ways,  if  the  periods  of  the  exalted  energizing, 
or  the  strain,  or  the  poisoning,  or  the  morbidness  is  only  short  in  time, 
and  the  organ  gets  rest  between  one  attack  and  the  next.  We  all  know 
that  periodic  sprees  may  be  continued  with  impunity  in  many  people  for 
a  lifetime,  and  that  many  men  may  safely  work  their  brains  at  full 
pressure  for  many  years  if  they  give  them  a  Sunday  rest  and  an  annual 
holiday. 

I  had  another  case,  a  lady,  T>.  C,  who  was  for  ten  years  in  the  asylum, 
who  took  attacks  of  excitement  lasting  about  a  fortnight  alternating  with 
periods  of  depression  for  a  week,  but  in  her  case,  as  in  that  of  D,  B.,  the 
depression  immediately  preceded  the  excitement,  and  the  periods  of 
sanity  were  about  three  weeks  in  duration.  But,  like  all  the  rest  of  the 
cases,  the  length  of  the  periods  of  tlie  different  conditions  was  not  abso- 
lutely uniform.  In  her  case,  also,  the  regular  alternations  went  on  up  to 
the  age  of  seventy-eight,  when  she  died;  occurring  only  in  a  mild  form 
during  the  last  six  months  of  her  life,  when  she  had  a  broken  leg,  an 
ulcerated  and  sloughing  ankle,  and  was  very  exhausted.  But  her  mind 
Avas  rather  enfeebled  during  the  quiet  "sane"  periods  for  the  last  ten 
years  of  her  life,  and  she  had  "sexual  delusions  about  men  wanting  to 
seduce  and  marry  her.     The  exhausting  effects  of  the  excitement  on  her 


STATES    OF    MENTAL    ALTERNATION.  177 

brain,  as  in  many  of  the  alternating  cases,  were  aggravated  by  her 
addiction  to  masturbation  during  the  exalted  periods. 

I  have  now  under  my  care  a  gentleman,  D.  D.,  aged  49,  who  for  the 
past  twenty -six  years  has  been  subject  to  the  most  regularly  recurring 
brain  exaltation  every  four  weeks  almost  to  a  day.  It  sometimes  passes 
off  without  becoming  acutely  maniacal  or  even  showing  itself  in  outward 
acts ;  at  other  times  it  becomes  so,  and  lasts  for  periods  of  from  one  to 
four  weeks.  It  is  always  preceded  by  an  uncomfortable  feeling  in  the 
head  and  pain  in  the  back,  a  mental  hebetude  and  slight  depression. 
The  7iisus  generativus  is  greatly  increased,  and  he  says  that  if  in  that 
condition  he  has  full  and  free  seminal  emission  during  sleep  the  excite- 
ment passes  off;  if  not,  it  goes  on.  Full  doses  of  the  bromide  and 
iodide  of  potassium  have  the  effect  sometimes,  but  not  always,  of 
stopping  the  excitement,  and  a  very  long  walk  will  at  times  do  the  same. 
When  the  exaltation  gets  to  a  height  it  is  followed  always  by  about 
a  week  of  stupid  depression.  It  seems  as  if  the  depression  in  those 
cases  always  meant  a  reaction  after  morbid  over-action — a  muddy  mental 
calm  after  a  storm,  an  anaesthesia  after  a  hyperaesthesia. 

In  the  following  case  the  alternations  began  in  old  age :  D.  C, 
ret.  74  on  admission,  unmarried,  has  had  several  attacks  of  excitement  in 
the  three  years  previously.  A  sister  is  insane,  and  brother  hemiplegic 
with  periodic  attacks  of  mild  mental  exaltation,  which  also  came  on  in 
advanced  life.  But  the  patient  had  been  a  staid,  industrious  man,  who 
had  been  in  business  all  his  life,  and  done  his  work  well  till  he  was  over 
seventy,  leading  a  sober  life.  He  has  been  excited  for  three  months. 
It  began  first  by  great  mental  exaltation  and  hilarity  of  manner.  He 
was  very  fond  of  the  ladies,  but  never  erotic.  Especially  he  used  to 
laugh  most  immoderately  at  nothing  in  particular,  putting  down  his 
stick  into  the  ground,  and  bending  forward  and  roaring  with  laughter 
from  five  to  ten  minutes  running.  This  had  exactly  the  effect  of  a  man 
laughing  well  and  continuously  on  the  stage,  at  a  cause  of  which  you  are 
ignorant ;  it  was  catching,  and  you  could  not  help  laughing  too.  This 
gradually  passed  into  a  stage  of  violence,  delusions  of  insults,  shouting, 
sleeplessness,  and  suspicion.  During  the  exalted  period  his  temperature 
was  always  over  99°,  he  ate  enormously,  craved  stimulants,  his  bowels 
were  moved  twice  a  day,  and  he  slept  little.  His  conduct  was  extremely 
ridiculous  for  an  old  man.  His  delusions  were  mere  fleeting  fancies  and 
suspicions.  In  four  months  from  the  beginning  of  his  attack  he  became 
depressed,  and  then  he  never  spoke,  looked  dull  and  heavy,  slept  well, 
and  got  fat,  but  his  bowels  became  very  costive.  All  his  brightness  and 
curiosity  and  much  of  his  intelligence  left  him.  He  took  no  interest  in 
anything.  There  was  much  of  stupor  in  his  state.  He  felt  little  mental 
pain.  After  about  two  months  he  got  over  his  dulness,  and  became 
practically  sane,  cheerful,  chatty,  and  contended.  After  three  months  of 
this  condition,  or  about  nine  months  fi'om  the  beginning  of  the  attack,  he 
gradually  got  exalted,  and  passed  through  exactly  the  same  phases 
as  before.  One  never  gets  pure  mental  exaltation  so  well  as  in  a  good 
case  of  alternating  insanity.  The  excitement  lasted  about  six  months, 
from  March  to  December,  being  very  mild  for  the  last  three  months ;  he 
then  passed  into  a  two  months'  attack  of  stupid  depression  as  before,  and 

12 


178  STATES    OF    MENTAL    ALTERNATION. 

•was  then  fourteen  months  well,  his  whole  circle  thus  taking  twenty-two 
months  to  complete.  He  next  got  exalted  in  December,  and  was  acutely 
excited  for  about  three  weeks  only,  and  then  had  an  attack  of  extreme 
stupor,  depression,  weakness,  and  prostration  for  three  months.  He  then 
became  sane ;  but  almost  at  once  passed  into  another  attack  of  excitement. 
The  whole  duration  of  this  circle  was  only  four  months.  The  excite- 
ment that  followed  was  more  acute  than  it  had  ever  been  before ;  it  lasted 
five  months,  and  was  followed  at  once  by  great  depression  lasting  six 
months.  He  was  then  sane  for  three  months,  this  circle  taking  fourteen 
months  to  complete.  This  time  he  became  exalted  in  May,  and  Mr. 
Geoghegan,  the  assistant  physician  in  charge,  thus  describes  him  :  "  Mr. 
D.  C.  is  abnormally  excited  and  emotional.  When  in  good  humor  he  is 
ridiculously  polite,  tells  the  most  pointless  story  over  and  over  again, 
laughs  louder  and  harder  at  it  each  time  it  is  told,  till  the  tears  run 
down  his  cheeks  and  he  has  to  hold  on  to  some  object  to  prevent  him  from 
falling ;  and  his  listeners,  by  pure  contagion,  are  in  much  the  same  con- 
dition. At  other  times  his  conversation  is  absurdly  religious,  and  he 
overdoes  the  part  of  a  sanctimonious  revivalist;  and  if  his  hearers  show 
any  want  of  gravity — a  hard  thing  to  avoid — he  gets  passionately  indig- 
nant, and  after  a  storm  of  displeasure  goes  off  in  high  dudgeon.  He  can 
never  bear  contradiction  or  difference  of  opinion  without  anger."  This 
circle  took  twenty-one  months  to  complete.  In  December  he  became 
exalted  again,  his  irritability  being  very  great  this  time,  and  his  hilarious 
happiness  less  marked.  He  remained  so  for  nine  months,  and  then 
became  depressed  rather  suddenly,  passing  into  a  condition  of  almost 
complete  stupor,  and  leading  an  almost  vegetative  life.  He  remained  so 
for  almost  five  weeks,  and  then,  without  the  usual  intermediate  period  of 
sanity,  he  suddenly  one  night  became  delirious  with  hallucinations  of  sight, 
but  this  only  lasted  for  one  day.  He  was  then  four  days  depressed,  and 
again  got  exalted,  with  more  decided  delusions  than  he  had  ever  had 
before.  This  lasted  less  than  two  months,  and  he  then  went  into 
an  attack  of  stupor  again.  By  this  time  he  was  eighty-two  years  of  age, 
and  he  had  an  epithelioma  of  one  of  his  great  toes,  with  irritation  and 
suppuration,  which  acted  as  a  drain  and  an  irritant.  This  toe  was  ampu- 
tated by  Mr.  Bell,  and  he  made  a  good  recovery,  and  he  gained  in  flesh 
and  strength,  but  has  remained  in  the  condition  of  depressed  partial 
stupor  ever  since  for  three  years,  lying  in  bed  mostly.  He  will  answer 
questions  when  spoken  to,  but  never  ventures  a  remark  or  takes  any 
notice  of  anything.  He  is  in  a  state  of  complete  senility  and  mental 
torpor. 

In  this  case,  as  in  most  of  the  others  that  I  have  seen  with  prolonged 
alternations,  they  were  irregular ;  but  in  him  the  periods  of  excitement 
always  began  in  cold  weather,  from  October  to  May.  The  most  striking 
circumstance  about  the  case  is  its  commencement  at  seventy-four,  after 
the  intensity  of  the  sexual  period  of  life  was  past.  It  is  only  the  second 
case  of  that  kind  I  have  known.  The  excitement  coming  on  in  spurts 
for  a  few  days  at  the  last,  as  if  the  senile  brain  had  no  longer  vigor 
enough  to  keep  up  a  prolonged  exaltation,  would  seem  to  be  the  natural 
ending  of  alternating  insanity,  whether  it  terminates  in  mild  or  complete 
senility,  or  in  dementia. 


STATES    OF    MENTAL    ALTERNATION.  179 

In  the  following  case  of  D.  B.,  the  attacks  of  excitement  and  those  of 
depression  ceased  at  the  age  of  sixty-five,  after  alternations  of  the  two 
had  lasted  for  twenty  years.  He  was  an  artist,  but  could  only  paint  at 
the  beginning  of  the  period  of  exaltation  and  at  the  end  of  it.  He 
never  could  finish  a  picture,  and  if  he  attempted  to  do  so  he  got  worse 
mentally.  So  long  as  painting  was  spontaneous  or  pleasurable  he  did  it, 
and  it  did  him  no  harm.  If  he  could  not  catch  a  likeness,  or  tried 
to  elaborate  or  paint  in  details,  or  had  nothing  but  drudgery  to  do,  he  got 
worse.  In  his  case  there  was  most  marked  exaltation  of  the  memory,  and 
his  fancies  always  took  the  pleasant  form  of  a  loss  of  his  own  personal 
identity  and  the  assumption  of  that  of  the  author  whose  works  he  was 
reading  or  repeating.  As  he  got  better  he  would  tell  me  that  he  was  very 
happy  indeed  as  he  lay  awake  at  nights,  for  he  would  fancy  he  was 
Shakespeai'e,  Burns,  or  King  David,  as  he  repeated  aloud  their  works. 
He  could  vividly  recall  the  events  of  his  boyhood,  and  repeat  long  con- 
versations he  had  held  with  his  friends  then.  His  eyesight  and  hearing 
became  very  acute,  so  that  he  could  read  small  print,  and  paint  without 
spectacles,  and  hear  whispers ;  while  as  the  exaltation  Avore  off  he  had  to 
use  stronger  and  stronger  spectacles,  and  was  very  deaf.  When  depressed, 
all  his  bodily  functions,  appetites,  and  propensities  were  torpid  and 
sluggish.  There  was  a  diiference  of  2.2°  between  his  average  temperature 
during  exaltation  and  depression.  There  is  in  the  case-books  of  the 
Carlisle  Asylum  a  careful  record  of  his  condition  from  1862  till  his  death 
in  1876.  ^t.  54,  1862,  January,  exalted ;  July,  pretty  well :  1863, 
July,  quite  well ;  October,  depressed  :  1864,  February,  exalted  ;  July, 
depressed ;  October,  quite  well :  1865,  April,  depressed ;  August, 
exalted:  1856,  January,  quite  well,  and  remained  so  till  1867,  when  in 
July  he  got  depressed,  and  in  December  his  alternations  were  diurnal,  he 
being  one  day  depressed  and  the  next  very  excited,  this  lasting  for  a 
month  or  two :  1868,  July,  became  depressed ;  October,  quite  well : 
1869,  April,  depressed,  and  Avas  so  till  October,  when,  instead  of  the 
usual  and  expected  exaltation,  he  got  quite  Avell,  and  kept  so  for  over 
three  years,  till  January,  1873,  when  he  had  a  short  attack  of  mild 
exaltation,  lasting  for  three  months.  He  then  kept  well  till  January, 
1874,  Avhen  he  had  a  fcAV  occasional  days  of  slight  excitement  at  irregular 
intervals,  and  then  got  quite  calm  and  rational,  though  not  energetic — in 
fact,  he  got  into  the  typical  and  normal  senile  condition  of  mind  and  body, 
his  brain  remaining  in  this  quiet  haven  of  rest,  after  its  tAventy  years  of 
violent  alternations  of  storm  and  sluggishness,  till  he  died  of  bronchitis 
in  the  end  of  1876,  at  sixty-eight.  In  this  case  it  will  be  observed  that 
there  Avas  a  distinct  tendency  for  the  periods  of  exaltation  to  occur  in 
the  early  part  of  the  year,  in  January  and  February,  and  the  periods  of 
depression  to  come  on  toAvards  the  end  of  the  year,  from  October  to 
December.  The  periods  of  depression  did  not  folloAV,  but  precede,  the 
exaltation  in  this  case,  contrary  to  the  usual  experience.  One  should 
perhaps  say  that  the  excitement  followed,  and  seemed  to  be  a  reaction 
from  the  depression. 

The  folloAving  dates  of  the  admission  and  discharge  of  D.  I.  show  the 
length  of  the  attacks  in  his  case,  for  he  is  sent  to  the  asylum  Avhenever  he 
gets  exalted,  and  is  sent  home  when  the  excitement  passes  off.    He  is  then 


180  STATES    OF    MENTAL    ALTERNATION. 

not  very  painfully  depressed,  quiet,  penurious,  and  unsocial,  sluggish  for 
two  or  three  months,  and  then  gets  quite  sane  and  does  his  business  very 
well.  His  exaltation  is  of  the  typical  kind,  talkative,  energetic,  passionate, 
quarrelsome,  abusive,  restless,  sleepless,  but  never  incoherent,  and  very 
fond  of  spending  his  money  lavishly.  He  once  got  off  to  London  about 
the  beginning  of  an  attack  Avith  £1000  in  his  pocket,  with  the  deliberate 
intention  to  spend  it  in  a  month  and  enjoy  himself,  as  he  said  he  had  "led 
too  quiet  a  life  at  home,"  and  he  pretty  nearly  got  through  it.  I  have 
reason  to  believe  that  he  once  made  a  large  sum  of  money  during  one  of 
his  exalted  brilliant  periods,  just  as  he  was  passing  into  the  elevated  part 
of  a  morbid  mental  circle.  Hopefulness,  superabundant  energy,  mental 
subtility,  argumentativeness,  wildness,  a  strong  leaning  towards  the  other 
sex,  but  not  an  offensive  eroticism,  characterize  this  period.  The  dates 
show  the  irregularity  of  the  seasons  at  which  the  attack  came  on,  and  of 
their  duration.  He  was  forty-five  when  first  admitted,  and  had  had  a  few 
attacks  previously.  Admitted  October,  1866,  discharged  January,  1867 ; 
admitted  April,  1870,  discharged  May,  1870 ;  admitted  August,  1871, 
discharged  September,  1871 ;  admitted  December,  1872,  discharged 
February,  1873;  admitted  February,  1875,  discharged  May,  1875; 
admitted  August,  1877,  discharged  September,  1877 ;  admitted  Novem- 
ber, 1880,  discharged  January,  1881;  admitted  December,  1881, 
discharged  March,  1882. 

An  examination  of  the  exact  periods  during  which  the  exaltation, 
depression,  and  sanity  persist,  their  relation  to  each  other  during 
different  recurrences,  and  the  sizes  and  regularity  of  the  successive 
circles  in  each  case,  shows  this  far  more  than  I  had  supposed  previously 
to  more  exact  investigation,  viz.,  that  the  periods  are  not  always  the  same 
in  the  same  patient  at  different  times,  and  that,  in  fact,  very  few  of  them 
are  regular  and  typical  in  their  symptoms.  I  only  find  about  one  or  two 
out  of  forty  cases  of  folie  circulaire  that  were  absolutely  regular.  In 
others  the  periods  of  excitement  were  often  twice  as  long  in  one  circle  as 
in  another,  and  the  periods  of  depression  and  sanity  varied  also.  The 
age,  state  of  the  general  health,  conditions  of  life,  critical  periods,  diet, 
medicines  such  as  combination  of  the  bromides  and  Indian  hemp,  have 
all  the  power  of  modifying  the  length  and  the  intensity  of  the  periods  of 
exaltation  particularly.  We  shall  see  how  important  those  facts  are, 
taken  in  conjunction  with  the  views  as  to  the  essential  nature  of  those 
alternations  which  I  am  to  speak  of. 

While  a  typical  case  of  alternating  insanity  is  not  hopeful,  yet,  in 
prognosis,  we  must  not  conclude  that  a  case  is  incurable  merely  because 
there  are  recurrences  and  alternations  for  a  few  months  or  for  a  year,  or 
even  for  two  or  three  years. 

It  is  very  interesting  and  most  important  to  study  minutely  the  ex- 
act psychological  differences  in  the  same  brain  when  morbidly  elevated, 
and  depressed,  and  sane  ;  and  it  is  almost  equally  important  to  compare 
the  differences  in  the  bodily  symptoms  of  the  two  former  conditions. 
The  cases  I  have  recorded  show  many  of  these  differences  and  symptoms. 
In  the  elevated  stage,  either  at  the  beginning  or  all  through  it,  there  is 
an  actual  exaltation  of  many  of  the  mental  faculties,  notably  of  memory, 
of  general  acuteness  and  ability  to  reason,  in  a  way.     The  mentalization 


STATES    OF    MENTAL    ALTERNATION.  181 

is  almost  unceasing  in  some  form  ;  the  common-sense  is  gone ;  the  power 
of  self-control  and  of  undertaking  definite  mental  work  is  gone  ;  the 
power  of  attention,  while  it  may  be  very  acute  in  some  ways,  is  not  under 
the  control  of  volition ;  there  is  a  childishness  of  mental  condition  in 
some  respects,  a  foolish  credulity ;  affectively  the  patient,  though  he  feels 
morbidly  happy,  yet  his  emotions  are  always  shallow  and  directed  in  fits 
and  starts  only  towards  objects  and  persons  that  are  present,  and  they 
are  always  weakened  towards  or  withdrawn  from  their  natural  objects, 
wife,  children,  etc.  There  is  a  most  remarkable  change  in  the  appetites, 
which  are  usually  quite  perverted  from  Avhat  was  natural  to  the  patient. 
Different  kinds  of  food,  drink,  and  stimulants  are  sought  for  and  enjoyed. 
The  general  feeling  of  bien-etre  is  exaggerated.  The  courage  is  exag- 
gerated, and  there  is  little  timidity  left.  There  is  an  intense  desire  to 
attract  attention.  There  are  always  extravagance  and  morbid  generosity. 
The  social  instincts  are  enlarged,  lowered  in  tone,  and  they  become  some- 
what promiscuous,  a  man  nearly  always  seeking  the  company  of  his  in- 
feriors in  station. 

In  the  stage  of  depression  the  natural  affections  towards  children 
usually  return  or  flow  into  their  natural  channels  with  much  force,  but 
the  subjective  feeling  of  the  patient  is  one  of  misery  and  ill-being :  he 
has  no  courage,  no  power  to  resolve,  no  general  activity  of  mind.  In  all 
the  typical  cases  there  is  a  sort  of  torpor  and  inactivity  of  mind ;  there 
is  niggardliness  in  money-spending,  in  wearing  clothes,  etc.  There  is 
often  a  feeling  of  profound  disgust  and  regret  at  the  extravagant,  foolish 
acts  of  the  excited  period. 

The  changes  in  the  bodily  symptoms  are  very  marked.  The  patient, 
when  exalted,  loses  weight ;  Avhen  depressed  he  gains  weight ;  the  differ- 
ence in  weight  between  the  two  periods  being  often  two  stones.  When 
excited  he  takes  much  exercise,  is  restless,  and  never  tires.  When  de- 
pressed he  is  sluggish,  and  dislikes  exercise,  and  is  soon  tired.  In  the 
former  stage  his  temperature  is  above  the  normal,  especially  in  the  even- 
ing ;  in  the  latter  below  it,  the  average  difference  being  1.1°,  and  in 
some  individual  cases  3.6°.  In  the  former  he  can  bear  cold  well,  and 
likes  it ;  in  the  latter  he  cannot  bear  cold,  and  dislikes  it  much.  In  the 
former  his  bowels  are  very  regular,  and  often  moved  more  than  once  a 
day  ;  in  the  latter  they  are  costive.  In  the  former  his  face  is  mobile  and 
expressive,  and  his  eyes  glistening ;  in  the  latter  they  are  heavy.  In  the 
former  he  is  always  hungry,  and  his  capacity  for  eating  and  digesting 
everything  almost  unlimited ;  in  the  latter  he  may  eat  well,  but  is  very 
particular  as  to  food.  In  the  former  ho  craves  stimulants  and  tobacco ; 
in  the  latter  he  often  loathes  them.  In  the  former  he  is  not  sensitive  to 
disagreeable  odors,  sounds,  and  sights ;  in  the  latter  he  is  usually  hyper- 
sensitive. In  the  former  the  skin  is  moist  and  perspiring ;  in  the  latter 
it  is  usually  dry  and  often  hard,  and  skin  diseases,  such  as  psoriasis,  not 
infrequently  appear.  While  exalted,  the  patient's  pulse  is  usually  full 
and  hard ;  while  depressed,  small  and  compressible.  In  the  former  the 
sexual  appetites  and  capacity  are  always  increased  ;  in  the  latter  they  are 
often  paralyzed.  (One  gentleman  toid  me  that  for  two  years  he  had  no 
sexual  feeling  or  power.)     The  sight  and  hearing  are  often  much  more 


182  STATES    OF    MENTAL    ALTERNATION. 

acute'  in  the  former  than  in  the  latter.  In  the  former  state  the  patient 
sleeps  little  and  lightly ;  in  the  latter  long  and  soundly. 

Many  ordinary  nervous  symptoms  follow  the  periodicity  and  alterna- 
tion of  the  mental.  1  had  one  woman  whose  circle  took  about  six  weeks 
to  complete,  and  whose  period  of  elevation  was  always  preceded  and 
ushered  in  by  severe  cephalalgia  and  then  by  vomiting.  I  have  had 
several  women  in  whom  the  depressed  period  was  preceded  by  neuralgia. 
Several  of  my  patients  can  tell  beforehand  when  they  are  going  to  get 
excited,  by  their  bodily  feelings.  One  form  of  alternation  has  been 
called  Katatonia  by  Kahlbaum.  It  is  an  alternating  insanity,  in  which 
there  are  either  epileptiform  symptoms  or  those  resembling  catalepsy, 
hallucinations  of  sight  and  hearing,  unconsciousness,  with  trophic  symp- 
toms, such  as  oedema  and  weak  pulse,  these  preceding  or  accompanying 
the  melancholic  stage.  It  is  simply  a  variety  of  the  disease  in  which  the 
functions  of  the  motor  and  trophic  centres  are  specially  involved. 

I  have  for  a  long  time  been  impressed  with  the  relationship  of  the 
mental  and  bodily  alternations  and  periodicity  in  insanity  to  the  great 
physiological  alternations  and  periodicities,  and  I  have  gradually  been 
led  to  the  conclusion  that  they  are  the  same  in  all  essential  respects,  and 
only  differ  in  degrees  of  intensity  or  duration.  By  far  the  majority  of 
the  cases  in  women  follow  the  law  of  the  menstrual  and  sexual  period- 
icity ;  the  majority  of  the  cases  in  men  folloAV  the  law  of  the  more  irregu- 
lar periodicity  of  the  nisus  genei'otivus  in  that  sex.  Many  of  the  cases 
in  both  sexes  follow  the  seasonal  periodicity,  which  perhaps  in  man  is 
merely  a  reversion  to  the  seasonal  generative  activities  of  the  majority  of 
the  lower  animals 

A  careful  clinical  study  of  mental  diseases  reveals  the  fact  that  there 
exists  in  by  far  the  majority  of  all  the  acute  cases,  at  some  time  or  other, 
in  some  form  or  degree,  in  the  course  of  the  disease,  a  tendency  to  alter- 
nation, periodicity  of  symptoms,  remissions,  or  recurring  relapses.  I 
have  taken  the  338  cases  of  mental  disease  admitted  to  Morningside 
Asylum  in  1881 — 181  of  them  being  cases  of  mania,  and  129  of  melan- 
cholia, the  rest  being  general  paralysis,  dementia,  etc. — and  I  find  that 
in  81  of  the  female  cases,  or -46  per  cent,  in  that  sex,  and  in  67  of  the 
men,  or  40  per  cent,  of  that  sex,  there  was  relapse,  alternation,  or 
periodicity  of  symptoms  in  the  course  of  their  attacks.  Many  of  the 
338  admissions  were  chronic  on  admission,  so  that  of  the  recent  cases  the 
decided  majority  showed  those  symptoms.  50  of  the  129  cases  of 
melancholia,  or  39  per  cent.,  and  98  of  the  181  cases  of  mania,  or  54 
per  cent.,  were  alternating  or  relapsing,  or  showed  diurnal,  or  monthly, 
or  seasonal,  or  sexual  periodicity.  It  may  therefore  be  concluded  that 
insanity  in  the  female  sex  has  more  of  this  character  than  in  men,  and 
that  the  cases  of  mania  have  it  to  a  greater  degree  than  those  of  melan- 
cholia. In  some  patients  it  was  a  morning  aggravation  and  evening  im^ 
provement,  those  being  usually  cases  of  melancholia ;  in  a  fcAV  it  was  an 
evening  aggravation,  those  being,  contradictorily,  also  cases  of  melan- 
cholia. Very  many  cases  of  mania  were  more  exalted  one  day  and  less 
80  the  next ;  many  sleeping  and  waking  on  alternate  nights,  these  being 
usually  cases  of  mania.  The  attendants  are  very  strong  on  this  point  of 
the  "good"  and  "bad  days"  of  these  patients,  and  calculate  much  on 


STATES    OF    MENTAL    ALTERNATION.  183 

them.  Many  of  the  cases  had  remissions  and  relapses  of  a  few  days 
regularly  for  a  time.  Some  had  monthly  or  menstrual  aggravations.  In 
some  cases  these  periodic  remissions  occurred  most  at  the  beginning  of 
the  attack,  but  in  far  more  cases  towards  the  end  of  it,  and  during  the 
convalescence  of  the  patient.  I  had  a  lady  lately  under  my  care,  con- 
valescing from  acute  mania — E,  K.,  a  strong,  healthy  woman  of  38, 
who  had  recently  recovered  from  a  bad  attack  of  rheumatic  arthritis. 
First  attack,  duration  ten  days.  Heredity  to  insanity.  She  remained 
in  a  state  of  acute  excitement  for  about  a  Aveek  after  admission,  getting, 
however,  at  intervals  sufficient  sleep  and  sufficient  nourishment.  An 
abatement  of  the  disease  then  set  in,  and  from  that  period  there  was  a 
slow  but  steady  improvement  until  seven  weeks  after  admission,  when 
she  Avas  discharged,  having  made  an  excellent  recovery.  The  most 
striking  feature  in  the  case,  during  the  latter  weeks  of  its  course,  was 
the  distinct  daily  morning  exacerbation  and  evening  remission.  Each 
morning  showed  a  distinct  improvement  on  the  previous  morning,  but  a 
distinct  relapse  as  compared  with  the  previous  evening,  while  each  evening 
she  appeared  to  be  further  on  the  road  to  recovery  than  she  was  the 
evening  before.  In  the  morning  she  would  be  full  of  doubts,  suspicions, 
and  querulousness,  while  the  evening  would  find  her  sensible,  cheerful, 
and  grateful.  The  change  would  come  on  in  a  few  minutes  without 
external  cause.  Even  when  convalescence  was  well  advanced,  the  morn- 
ing was  for  her  a  period  of  distress  and  distrust,  but  with  the  evening 
came  quiet,  rest,  and  a  thankful  heart. 

Such  a  case  is  merely  a  type  of  what  is  very  common  during  all  forms 
of  mental  disease,  especially  during  convalescence.  A  medical  man  in 
attendance  should  always  prepare  the  minds  of  relatives  for  this  tendency 
to  relapse  and  alternate.  Nothing  is  more  discouraging  to  both  the 
doctor  and  the  relations,  when  it  persists  for  a  long  time ;  but  it  is  our 
duty  to  keep  up  their  hopes  and  ours,  and  to  think  of,  and  refer  to 
examples  where  the  tendency  has  been  quite  got  over,  even  after  a  long 
time.  I  once  had  a  young  man  of  twenty  who  took  regular  relapses  for 
five  years,  and  after  that  made  an  admirable  recovery,  and  to  my  own 
knowledge  has  done  his  work  well  and  has  kept  well  for  ten  years. 
Taking  the  chronic  incurable  cases  now  in  the  Asylum,  I  find  that  about 
forty  per  cent,  of  them  are  subject  to  aggravations  of  their  diseases  at 
times. 

I  find  that  the  younger  the  patient  the  greater  is  the  tendency  to 
periodic  alternation,  remission,  and  relapse.  The  phenomenon  finds  its 
acme  in  the  cases  of  pubescent  and  adolescent  insanity. 

I  also  find  that  the  stronger  the  heredity  the  greater  the  tendency  to 
periodic  relapses  and  alternations.  I  have  never  met  with  a  single  case 
that  could  be  called  typical  folie  circulaire  where  there  was  not  hereditary 
predisposition  to  insanity.  It  seems  as  if  there  were  certain  brains  so 
constituted  as  to  be  incapable  of  energizing  except  irregularly,  swinging 
between  elevation  and  depression,  like  a  bad  electric  light.  The  above 
facts  and  statistics  refer  to  ordinary  remissions ;  but  the  infrequency  of 
cases  Avith  such  regular  and  continuous  alternations  as  to  be  properly 
called  folie  circulaire  may  be  seen  from  the  fact  that  out  of  eight 
hundred  patients  in  the  Asylum  at  Morningside  now  there  are  only  six- 


184  STATES    OF    MENTAL    ALTERNATION. 

teen  of  this  kind,  or  two  per  cent.,  and  of  the  h\st  three  thousand  new 
admissions,  comprising  about  two  thousand  fresh  cases  of  insanity,  less 
than  ten  have  as  yet  turned  out  of  this  character.  But,  of  course,  I  do 
not  include  the  cases  with  merely  long  remissions,  or  the  c;ises  with 
relapses  for  the  first  year  or  two,  or  the  demented  cases  with  occasional 
spurts  of  excitement,  or  the  women  with  a  few  irritable  days  at  menstru- 
ation, though  many  of  these  are  of  the  same  essential  nature  as  the  most 
typical  cases  oi  folic  circulaire,  following  the  same  laws  of  physiological 
periodicity  in  an  irregular  way. 

I  have  had  under  my  care  altogether  about  forty  cases  of  typical  folie 
circulaire.  Of  these  about  one-half  followed  a  more  or  less  regular 
monthly  periodicity.  About  one-third  obeyed  the  law  of  seasonal  period- 
icity, all  in  an  irregular  way ;  and  the  remaining  sixth  I  could  bring 
under  no  known  law  on  account  of  their  irregularity.  I  have  one  extra- 
ordinary case  now,  a  lady,  who  was  for  a  year  deeply  depressed,  then  for 
several  years  quite  well,  then  for  seven  years  more  deeply  depressed,  then 
for  three  months  passed  for  sane,  but  was  really  mildly  exalted,  then  was 
depressed  for  a  year,  and  has  now  been  exalted,  with  all  the  typical 
symptoms  of  typical /oZ/e  circulaire,  for  two  years. 

Commencement  of  the  Alternating  Tendency. — Though  there 
are  a  few  cases  that  begin  with  attacks  of  melancholia,  yet  in  my  experi- 
ence^ at  least  ninety  per  cent,  begin  with  attacks  of  maniacal  exaltation. 
The  ages  of  the  patients  on  the  first  breaking  out  of  the  disease  were  all 
the  way  from  fifteen  to  seventy-four;  but  every  one,  except  the  one  D.  C. 
(p.  177),  began  within  the  actively  sexual  and  procreative  period  of  life. 
I  find  no  record  of  a  woman's  case  beginning  after  the  climacteric  period. 

Termination  of  Typical  Folie  Circulaire. — As  this  cannot  be 
determined  till  after  the  patients  have  died,  it  is  impossible  for  me  to  give 
accurate  figures;  but,  of  forty  cases,  five  ceased  to  be  subject  to  alterna- 
tion in  old  age  after  sixty,  one  of  these  was  above  eighty,  two  being 
women.  The  men  were  all  left  in  a  condition  of  mind  and  brain  that 
might  be  legally  reckoned  sanity,  though  in  all  cases  there  was  some 
mental  enfeeblement  or  a  tendency  to  be  easily  upset,  with  lethargy,  want 
of  spontaneity,  and  of  volitional  power.  One  case  terminated  in  complete 
dementia.  Two  ran  on  into  chronic  mania.  Two  died  of  exhaustion 
during  a  maniacal  period.  Three  things  are  sure  about  the  prognosis — 
1.  Its  utter  uncertainty.  2.  Recovery  cannot  be  looked  for  at  the 
climacteric  period  in  many  cases.  3.  About  twenty  per  cent,  may  be 
expected  to  settle  down  into  a  sort  of  quiet,  comfortable,  slightly  enfee- 
bled condition  in  the  senile  period  of  life.  4.  In  my  experience  very 
few,  indeed,  become  completely  demented.  5.  The  tendency  to  death  is 
very  slight. 

General  Conclusions. — Looking  at  all  those  facts  and  considerations, 
therefore,  I  come  to  these  conclusions.  That  periodicity  or  a  tendency 
to  alternations  of  elevation  and  depression  is  an  almost  universal  charac- 
teristic of  mental  diseases;  that  it  is  much  more  marked  where  they  are 
very  hereditary  than  in  any  other  cases;  that  it  is  more  common  in 
youth,  puberty,  and  adolescence  than  at  other  periods ;  that  it  is  in  its 
essential  nature  merely  the  exaggerated  or  perverted  physiological 
diurnal,  menstrual,  sexual,  or  seasonal  periodicities  of  the  healthy  brain : 


STATES    OF    MENTAL    ALTERX  ATI  ON.  185 

that  the  cases  that  have  been  called  folie  ciretilaire,  katatonia,  etc.,  are 
merely  typical  or  exaggerated  or  more  continuous  examples  of  that 
universal  tendency  to  which  I  have  referred.  Another  remarkable  fact 
about  the  typical  form  of  alternating  insanity  is,  that  by  far  the  greater 
number  of  pereons  who  suffered  from  it  were  persons  of  education,  and 
far  more  than  a  due  proportion  of  them  were  persons  of  old  families.  I 
never  met  with  a  fine  case  in  a  person  whose  own  brain  and  whose 
ancestors'  brains  had  been  uneducated.  It  seems  to  me  that  the 
tendency  to  alternation  of  mental  condition,  to  energize  at  one  time  with 
morbid  huny  and  then  with  morbid  slackness,  is  one  of  the  forms  of  brain 
instability  which  specially  results  from  too  much  "pureness  of  blood,"  or 
from  the  heredity  of  many  generations  of  gentlefolks,  all  of  whose  brains 
had  been  more  or  less  educatetl.  Probably  it  is  one  of  the  modes  by 
which  nature  brings  that  kind  of  stock  to  an  end  that  has  become  bad  by 
over-brain  cultivation  for  many  generations. 

Real  work  can  sometimes  be  done  during  the  sane  periods.  D.  D.  has 
done  some  literary  work,  in  the  intervals  of  his  attacks,  for  the  twenty- 
six  years  he  has  been  ill. 

I  have  no  doubt  that  it  was  the  sexual  and  menstrual  periodicity  of 
mental  diseases,  seen  in  so  many  cases,  that  formerly  originated  the 
absurd  idea  that  they  depended  on  the  moon's  changes,  and  gave  them  the 
name  of  '"lunacy." 

Treatment. — The  great  point  in  treatment  is  to  prevent  the  brain 
getting  into  the  vicious  circle  of  continuous  alternation  by  endeavoring 
really  to  complete  the  cure  in  all  cases  of  mania — especially  in  all  cases  of 
adolescent  mania — and  by  prolonged  quiet  and  brain-rest  after  attacks  in 
persons  who  have  shown  a  tendency  towards  recurrence  and  relapse.  In 
them  particularly  the  whole  organism  should  be  kept  up  to  physiological 
perfection.  I  believe  that  a  non-stimulating  farinaceous  vegetable  diet 
and  no  alcohol  is  the  best  for  them,  with  an  outdoor  life  and  plenty  of 
muscular  exercise.  A  regular  mode  of  life,  too,  without  excitement,  is 
best.  One  thing  which  I  have  heard  recommended,  and  which  is  very 
liable  to  be  resorted  to  in  the  beginning  of  the  exalted  stage  when  the 
patient  is  very  erotic,  is  marriage,  but  I  have  never  seen  any  good  come 
of  it  either  by  cure  or  prophylaxis.  I  once,  with  Dr.  Heron  Watson,  had 
to  stop  the  banns  in  the  case  of  a  lady  who  had  been  seduced  in  the  begin- 
ning of  the  exalted  erotic  stage  of  this  disease,  and  was  going  to  be 
married  for  her  money  by  a  scoundrel  who  had  taken  advantage  of  her 
mental  condition.  I  mentioned  in  the  case  of  D.  A.  that  he  usually  pro- 
posed to  many  ladies  at  the  beginning  of  his  exalted  attacks.  There  is 
only  one  class  of  medicines  that  I  know  which  have  any  power  of  stop- 
ping or  cutting  short  attacks,  and  of  sometimes  averting  them  for  a  long 
time,  and  these  are  the  bromides,  especially  combined  at  the  more  acute 
stages  with  Indian  hemp.     The  following  three  cases  illustrate  this  action : 

D.  F.,  set.  23.  This  young  woman  has  had  six  attacks  of  mania  in 
four  years.  She  had  been  insane  for  four  weeks  previous  to  admission. 
All  the  attacks  had  begun  during  mensti-uation.  and  while  maniacal  she 
was  always  very  erotic,  especially  at  the  beginning  of  the  excitement. 
She  was  violent,  incoherent,  noisy,  dirty  in  her  habits,  and  sleepless 
before  admission  and  for  about  three  months  afterwards.     She  then  got 


186  STATES    OF    MENTAL    ALTERNATION. 

well,  but  in  six  months  had  another  similar  attack  of  mania,  lasting  for 
two  months.  She  lost  twenty-eight  pounds  in  weight  during  this  attack, 
and  her  temperature  was  always  1.5°  above  its  normal  rate  during  the 
excitement.  She  remained  free  from  excitement  for  nine  months,  and 
then  had  another  similar  attack.  After  four  months  of  sanity  she  one 
night  suddenly  got  up,  smashed  the  windows  of  her  dormitory,  saying 
that  the  devil  was  looking  in,  and  became  violently  excited,  her  tempera- 
ture that  day  being  100.8°,  pulse  108  and  strong.  She  was  ordered 
drachm  doses  of  the  bromide  of  potassium  every  three  hours,  with  a 
drachm  of  ammoniated  tincture  of  valerian  with  each  dose.  She  was 
put  into  a  dark  room  at  her  own  suggestion.  On  the  following  day  her 
temperature  was  99.6°,  and  her  pulse  108.  She  was  still  much  excited, 
but  not  so  much  as  on  the  day  before.  On  the  second  day  her  tempera- 
ture was  99.3°,  and  her  pulse  130  and  weak,  the  excitement  being  much 
allayed.  The  medicine  was  after  this  given  only  three  times  a  day. 
She  Avas  left  in  bed  for  a  fortnight  in  a  dark  room,  as  she  said  that  if  she 
got  up  she  would  get  worse.  At  the  end  of  that  time  she  was  still 
rambling,  partially  incoherent,  and  full  of  delusions,  but  nearly  free  from 
active  excitement,  and  the  medicine  was  discontinued.  She  remained 
slightly  affected  in  mind  for  another  fortnight.  At  the  end  of  a  month 
from  the  day  the  excitement  began  she  was  well,  and  was  discharged 
from  the  asylum  six  months  thereafter.  I  heard  that  she  was  still  keep- 
ing well  a  year  from  the  time  of  her  attack  of  mania,  which  was  thus  cut 
short  (as  it  seems  to  me)  by  bromide  of  potassium.  I  gave  the  valerian 
because  she  was  beginning  to  menstruate  at  the  time  the  mania  began. 

It  will  be  observed  that  the  excitement  in  this  attack  only  lasted  about 
three  days,  and  she  had  never  been  less  than  two  months  excited  at  a 
time  in  her  nine  previous  attacks.  The  aberration  of  mind  was  only  of 
a  month's  duration.  It  had  never  been  shorter  than  between  three  and 
four  months  previously,  every  symptom  of  an  ordinary  attack  being 
clearly  present  at  first ;  and  the  interval  of  sanity  has  been  even  now 
longer  than  any  such  interval  except  that  between  the  fifth  and  sixth  at- 
tacks. The  excitement  disappeared  as  the  patient  showed  signs  of  coming 
under  the  influence  of  the  bromide,  and  its  constitutional  symptoms  were 
developed. 

D.  G.,  set.  5Q,  a  woman  who  has  been  rather  weak-minded  from  birth, 
but  got  married  and  had  children.  She  has  been  subject  to  attacks  of 
excitement  at  intervals  of  a  year  or  two  for  twenty  years.  On  her  ad- 
mission from  another  asylum  she  was  found  to  be  a  little,  thin  woman, 
who  went  on  talking  quite  incoherently,  was  restless  and  destructive  to 
her  dress,  and  violent  at  times.  Sometimes  she  refused  her  food,  and 
had  to  be  fed  with  the  stomach-pump.  Though  she  got  much  food  and 
stimulants,  she  became  quite  run  down,  thin,  and  exhausted  in  mind  and 
body  before  the  attack  was  over.  The  first  attack  lasted  from  March  till 
the  following  January  ;  she  had  a  short  attack  in  April.  In  the  begin- 
ning of  the  next  year  she  had  another  short  attack,  and  in  the  December 
following  she  had  three  epileptic  fits  (the  first  she  ever  had).  They  were 
the  prelude  to  an  attack  of  excitement  which  lasted  for  six  months.  In 
the  following  year  she  had  another  attack  of  excitement  lasting  for  three 
months.     In  the  beginning  of  this  year  she  again  became  excited,  and 


PLATE       IV. 


STATES    OF    MENTAL    ALTERNATION.  187 

was  put  on  drachm  doses  of  bromide  and  tincture  of  Indian  hemp,  three 
times  a  day  at  first,  and  afterwards  morning  and  evening.  The  medicine 
BO  completely  moderated  all  the  unpleasant  symptoms  of  the  excitement 
that  she  was  kept  in  the  infirmary  ward  among  the  sick  patients.  She 
was  not  noisy,  destructive,  or  dirty  in  her  habits,  as  she  had  been  before; 
she  did  not  lose  flesh  to  nearly  the  same  extent  as  before ;  she  took  her 
food  better  than  ever  she  had  done  before  during  excitement ;  and  the 
attack  terminated  in  September,  leaving  her  far  stronger  than  she  had 
ever  been  after  so  long  an  attack  of  excitement. 

This  case  illustrates  the  effect  of  the  medicine  on  an  old  person  very 
weak  in  body,  and  perhaps,  therefore,  more  amenable  to  the  eifects  of  the 
drug.  Such  cases,  when  violently  excited,  are  far  Averse  to  manage  and 
cause  far  more  anxiety  than  stronger  patients  in  asylums,  and  therefore 
it  is  more  important  to  have  a  mild  and  safe  sedative. 

Another  case  is  that  of  an  old  woman  who  has  taken  periodic  attacks 
of  mania  for  at  least  twenty  years,  and  has  been  so  much  better  during 
her  last  attack,  under  the  use  of  drachm  doses  of  the  bromide  and  tinc- 
ture of  cannabis  morning  and  evening,  that  she  has  been  kept  in  the  in- 
firmary Avard  of  the  asylum  during  the  nine  months  the  attack  has  lasted, 
and  has,  during  that  time,  slept  in  a  dormitory  with  other  patients,  has 
taken  her  food,  and  is  now  passing  into  the  quiet  stage  of  her  disorder. 

Pathology. — As  regards  the  pathological  appearances  found  after 
death  in  cases  of  prolonged  alternating  insanity,  I  found  in  all  of  them 
more  or  less  brain  atrophy,  especially  affecting  the  convolutions,  in  all 
of  them  thickening  of  the  membranes,  in  most  of  them  thickenino;  of  the 
skull  cap.  One  case,  who  had  been  twenty-five  years  ill,  showed  an 
amount  of  deposit  of  bone  on  the  inner  table  of  the  skull  I  have  never 
seen  before  (see  Plate  IV.).  In  most  of  them  there  was  vascular  disease, 
with,  in  one  or  two  cases,  local  disintegration  from  embolisms  and  other 
results  of  blood-starvation.  In  short,  I  found  the  common  pathological 
appearances  in  cases  of  chronic  insanity,  but  Avith  no  special  pathology 
whatever.  That  is  Avhat  might  be  expected,  for  at  the  beginning  the 
mental  functions  are  so  nearly  restored  betAveen  the  attacks  that  Ave  can 
expect  no  marked  pathological  changes.  The  Avhole  tendency  to  periodi- 
city results,  no  doubt,  from  a  mode  of  energizing,  and  not  from  struc- 
tural change  that  can  be  seen  after  death.  No  doubt  such  a  deposit  as 
that  figured  in  Plate  IV.  is  secondaiy  and  partly  compensatory  for  the 
brain  atrophy,  but,  like  many  of  the  changes  of  structure  in  the  bones 
and  membranes  of  the  brain  in  chronic  insanity,  it  is  very  instructive  in 
the  light  it  sheds  on  the  pathogenesis  of  the  disease.  If  the  intensity  of 
the  morbid  action  Avas  so  great  as  to  cause  such  structural  changes  even 
in  the  bones,  how  great  must  it  have  been  in  the  convolutions,  its  primary 
seat! 


LECTURE    YI. 

STATES  OF  FIXED  AXD  LIMITED  DELUSION  {MOXOMANIA,  MONO- 
PSYCHOSIS, DELUSIOXAL  lySAXITF). 

The  study  of  this  form  of  mental  aberration  should,  like  that  of  every 
other  form,  he  begun  from  a  physiological  point  of  view.  There  are  all 
sorts  of  false  sense  impressions  and  false  intellectual  beliefs  which  are 
due  to  mere  physiological  laws.  When  a  light  is  rapidly  intermittent 
and  appears  to  the  eye  to  be  continuous,  when  the  sensation  of  the  toes 
and  their  movements  are  felt  in  an  amputated  stump,  and  when  one  is 
deceived  by  the  quick  movements  of  a  juggler,  we  have  for  the  time 
sense  delusions.  When  through  brain  fatigue,  brain  poisoning,  or  dis- 
turbance of  the  circulation,  objects  are  seen  double  ;  or  when  the  old  im- 
pressions on  the  perceptive  centres  of  the  brain  are  projected  and  appear 
to  be  seen  as  real  objects,  the  true  nature  of  which  have  to  be  ascertained 
by  the  judging  faculty,  we  have  real  hallucinations,  but  not  insane  hal- 
lucinations. The  whole  mental  life  of  a  child  in  its  very  early  years, 
before  its  senses  are  trained  or  its  judging  power  developed,  is  one  series 
of  delusions.  The  superetitions  of  the  ignorant  are  delusions,  but  they 
result  from  lack  of  training  and  want  of  development  of  the  judging 
power,  not  from  a  diseased  perversion  of  it.  When  lately  a  great  part 
of  the  Mohammedan  population  of  Constantinople  turned  out  one  night, 
and  with  frantic  gesticulations,  great  shouting,  and  firing  of  guns,  tried 
to  frighten  away  a  beast  which  they  believed  to  be  devouring  the  moon 
when  it  was  eclipsed,  they  labored  under  a  delusion  of  ignorance.  I 
have  heard  a  perfectly  sane  but  ignorant  woman  in  Cumberland  say  that 
every  time  she  had  sat  by  the  bedside  of  a  dying  person,  she  had  heard 
the  "  Death  Clock"  in  the  wall;  and  whenever  she  heard  that,  she  knew 
the  patient  was  going  to  die,  and  had  never  been  deceived.  You  meet 
with  people  who  believe  that  certain  things  are  going  to  happen  on 
utterly  absurd  grounds,  and  so  labor  under  delusions  in  a  popular  sense. 
Dreaming  and  nightmare  give  you  the  best  idea  of  an  insane  delusion. 
and  are  the  nearest  physiological  counterparts  of  it.  A  suificient  amount 
of  fatigue  and  exhaustion  from  want  of  sleep  will  produce  a  condition  in 
almost  any  brain  that  is  closely  allied  to  that  of  the  monomanaic. 

Such  "delusions"  have  little  relationship  practically  to  "insane  de- 
lusions," however  much  they  may  resemble  them  in  certain  respects,  or 
however  much  they  may  be  psychologically  allied  to  them.  The  delu- 
sions that  are  really  half-way  house  between  those  I  have  referred  to 
and  the  true  insane  delusions  are  the  false  beliefs  of  imbeciles  and  the 
temporary  delusions  of  persons  whose  emotions  have  been  strongly 
roused  by  religious  services  or  contemplation,  as  when  they  see  visions 
or  hear  voices.     The  imbecile  has  deficient  judging  power  from  want  of 


X 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  189 

brain  development,  and  often  has,  in  addition,  morbid  energizing  of  his 
convolutions.  His  delusions  have  often  to  be  treated  as  insane  delu- 
sions, as  when  he  imagines  he  is  married  to  a  woman,  and  wants  to  act 
on  his  belief,  or  when  he  thinks  his  neighbor's  property  is  his  own,  and 
proceeds  to  use  it.  To  us,  as  practitioners  of  medicine,  the  "  insane 
delusion"  is  the  one  that  affects  the  conduct  or  life,  provided  it  results 
from  a  morbid  condition  of  brain,  either  through  deficiency  or  disease. 
An  educated  man  who  behaved  in  Princes  Street  as  the  Turks  behaved 
during  the  eclipse  Avould  certainly  be  regarded  as  laboring  under  an 
insane  delusion,  and  would  run  much  risk  of  being  sent  to  an  asylum. 
The  education,  age,  class,  and  even  race  in  some  degree  determine 
whether  any  given  false  belief  is  an  insane  delusion  or  not.  This  is  not 
perhaps  scientific  psychology,  but  it  is  the  practical  way  we  have  to  look 
at  the  matter  as  physicians.  The  whole  subject  of  false  sense  percep- 
tions, sane  hallucinations,  and  unreasoning  unfounded  "instincts"  about 
things,  though  most  interesting  both  from  the  physiological  and  medico- 
psychological  side,  I  must  not  dwell  on  here  too  long. 

An  "  insane  delusion"  may  therefore  be  defined  to  be  ."a  belief  in 
something  that  would  be  incredible  to  sane  people  of  the  same  class, 
education,  or  race  as  the  person  who  expresses  it,  this  resulting  from 
diseased  working  of  the  brain  convolutions.  '  There  was  once  an  old 
gentleman,  D.  L.,  a  patient  in  Morningside  Asylum,  who  in  his  man- 
ners and  conduct  was  all  that  was  gentlemanly ;  in  his  emotional  nature 
was  benevolent  to  a  high  degree;  and  in  his  dress  and  deportment  ex- 
hibited no  peculiarity  whatever,  but  who  calmly  asserted  that  he  was 
many  thousand  years  old;  that  he  had  known  Noah  rather  intimately, 
and  found  him  a  most  sociable  man,  but  "a  little  too  fond  of  his  toddy;" 
that  he  once  went  out  snipe-shooting  with  King  David,  who  was  a  crack 
shot ;  and  one  day  gave  St.  Paul  a  lift  on  his  gig  on  the  Peebles  road. 
I  once  had  a  patient,  D.  M.,  at  the  Carlisle  Asylum,  who  was  acute 
intellectually  and  morally  irreproachable,  but  who,  ever  after  a  hemi- 
plegic  attack,  believed  that  twice  two  were  not  four,  but  four  and  a 
quarter,  and  who  spent  his  whole  time  not  devoted  to  keeping  the  asylum 
accounts — which  he  did  accurately  on  the  "old  system"  in  deference  to 
our  prejudices — to  making  elaborate  calculations  by  his  own  mode  of 
arithmetic  as  to  the  distances  of  the  stars  and  a  new  system  of  loga- 
rithms, constructing  new  quadrants,  etc.  The  manuscripts  filled  two 
large  chests  at  his  death,  which  he  solemnly  left  by  will  to  the  Univer- 
sity of  Oxford.  In  both  these  cases  there  was  no  trace  of  the  morbid 
mental  depression  or  the  exaltation  that  I  have  described.  The  delu- 
sions, which  were  perfectly  fixed  and  unchanging  from  year  to  year 
during  the  lifetime  of  the  patients,  really  constituted  the  insanity,  and 
were  examples,  therefore,  of  delusional  insanity  or  monomania.  There 
are  very  few,  if  any,  examples  of  a  pure  monomania — that  is,  of  a 
person  who  has  one  single  delusion,  and  that  alone.  The  ordinary  form 
of  this  type  of  mental  disturbance  is  for  the  delusions  of  the  patient  to 
refer  to  one  particular  subject  or  set  of  subjects,  or  for  him  to  be  morbid 
in  a  particular  direction  of  intellect  or  feeling,  while  he  is  sound  in 
most  directions.      The  chief  directions  such  delusions  take  are — a.  of 


190  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

unreal  greatness,  h.  unfounded  suspicions,  and  c.  unseen  and  impossible 
agencies. 

Monomania  of  Grandeur  or  Pride. — I  have  a  pauper  patient, 
D.  N,,  who  believes  himself  to  be  the  rightful  king  of  England.  He 
looks  sane,  and  is  perfectly  quiet  and  self-possessed  in  manner.  He  is  a 
well-developed  man,  far  above  the  average  of  his  class  in  general  looks 
and  in  facial  expression.  He  told  us  his  story  with  perfect  calmness 
and  coherence,  rather  apologetically,  and  saying  he  knew  we  would 
probably  not  believe  him  if  he  said  he  was  heir  to  the  throne.  Then 
when  he  came  to  tell  about  his  betrothal  at  thirteen  to  Queen  Victoria 
(I  have  had  a  score  of  patients  who  were  to  have  been  married  to  her 
Majesty),  and  Prince  Albert's  adroitly  slipping  in,  he  got  on  to  ground 
purely  imaginary  and  delusional.  The  whole  story  Avas  a  queer  mixture 
of  wholly  imaginary  premises  and  much  sound,  but  also  much  unsound, 
conclusions  from  them.  Insane  people  generally  do  not  reason  rightly 
from  wrong  premises,  as  Loche  said,  but  some  of  them  do;  and  the 
simply  delusional  and  the  melancholic  cases  are  usually  the  classes  who 
approich  nearest  to  this  description.  It  is  most  difficult,  if  you  believe 
his  case  is  incurable,  to  pick  a  flaw  in  the  reasoning  of  a  melancholic 
who  says,  "I  am  miserable  and  incurably  ill,  and  shall  get  worse,  and 
lose  what  reason  I  have  got.  I  believe  all  such  people  are  better  out  of 
the  way.  I  have  all  my  life  believed  this ;  therefore,  I  mean  to  put  an 
end  to  myself  as  soon  as  possible."  One  premise  is  correct,  and  the 
other  was  held  by  him  to  be  so  when  he  was  quite  sane,  and  is  held  by 
many  sane  people.  But  in  the  case  of  the  monomanaic,  one  of  his  pre- 
mises is  indubitably  wrong  in  the  estimation  of  all  sane  people,  but  you 
cannot  convince  him  of  this.  If  twice  two  and  two  had  made  four  and 
a  quarter,  as  D.  M.  said  it  did,  then  it  was  not  absurd  to  have  devoted 
every  spare  moment  of  his  life  to  the  demonstration  that  the  world  had 
fallen  into  a  serious  error,  and  to  working  out  a  new  system  of  astronomy 
and  logarithms  on  a  correct  basis.  D.  N.,  the  king,  is  an  excellent 
blacksmith,  and  we  get  him  to  work  at  his  trade  in  our  shop.  Nowa- 
days we  do  not  allow  our  monomaniacs  or  insane  people  generally  to 
dress  themselves  or  to  look  like  what  they  believe  themselves  to  be,  as 
they  did  of  old.  The  antipathy  to  individualism  which  affects  society 
in  every  direction  is  strong  in  asylums  for  the  insane.  We  now  dis- 
courage those  outward  manifestations  of  insane  delusions  that  used  to 
give  a  lunatic  asylum  its  most  striking  character.  The  monarchs  crowned 
with  straw,  the  duchesses  in  gaudy  spangles,  the  field-marshals  with  gro- 
tesque military  uniforms,  that  could  be  seen  in  any  asylum  of  old,  you 
will  not  now  see  when  you  go  through  our  wards.  If  the  man  with  the 
millions  of  money,  who  is  the  rightful  heir  to  the  throne,  affixes  the  top  of 
a  soda-water  bottle  to  the  front  of  his  cap  as  a  faint  symbol  of  his  position, 
it  is  at  once  unfastened.  If  the  princess,  who  is  the  greatest  beauty  in 
Europe,  bedecks  herself  too  conspicuously  with  bits  of  colored  glass  and 
in  conspicuous  ribbons,  they  are  quietly  removed  at  night.  The  insane 
man,  liKe  his  sane  brother,  in  most  cases  soon  adapts  himself  to  his  circum- 
stances, and  submits  to  rule  and  public  opinion.  The  last  of  the  great 
characters  of  the  older  period  of  this  asylum,  D.  0.,  lived  on  into  the 
present  regime^  and  was  allowed  to  wear  the  insignia  of  his  rank,  but  I 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  191 

have  alloAved  no  successor  to  arise.  He  was  the  "  King  of  Kings,"  and 
wore  a  most  ehiborate  crown  of  many  colors,  each  part  of  which  had  a 
symbolic  meaning.  He  Avas  so  picturesque  a  character  about  the  place, 
and  was  so  striking  a  clinical  illustration  of  monomania  of  grandeur,  and 
withal  so  harmless  and  useful  in  the  garden,  that  I  never  ordered  him  to 
be  discrowned.  He  had  certain  visions  from  heaven  which  he  reduced 
to  concrete  forms  in  drawings  and  polished  stones,  and  his  relations  with 
Queen  Victoria  were  most  intimate.  One  "  cloud  of  the  Lord  "  which 
he  once  saw  on  the  top  of  St.  John's  Church,  had  taken  most  vivid  hold 
on  his  imagination,  for  he  cut  likenesses  of  it  on  the  bark  of  almost  every 
tree  in  the  asylum  grounds,  Avhere  they  will  remain  for  perhaps  hundreds 
of  years.  The  tendency  to  symbolism  and  morbid  outward  decoration  is 
much  stronger  in  the  Celtic  races  than  in  the  Teutonic,  and  in  the  female 
than  in  the  male  sex.  In  the  Highland  asylums  it  is  almost  impossible 
to  make  the  patients  abandon  their  conceits  in  dress.  Such  changes  have 
their  drawbacks,  for  no  Dean  Ramsay  of  the  future  will  be  able  to  compile 
for  us  such  delightful  stories  of  our  fools,  and  our  writers  and  artists  will 
have  to  look  out  for  less  striking  environments  for  their  madmen  than 
fool's  caps  and  gewgaws,  or  chains  and  filth. 

Hallucinations  of  the  senses  are  very  common  in  this  whole  class,  and 
also  delusions  as  to  the  identity  of  the  persons  around  them.  I  have  a 
gentleman  patient  who,  whenever  he  goes  into  Edinburgh,  meets  the  late 
Emperor  of  the  French,  or  the  late  Prince  Consort.  So  marked  is  this 
tendency  in  some  cases  that  it  might  be  called  a  special  form  of  mono- 
mania, that  namely  of  mistaken  identity.  It  is  well  illustrated  in  this 
letter  of  D.  0.  A. : 

"  My  deak  Mamma, — I  have  been  long  in  answering  your  last  kind  letter,  but 
the  real  reason  is  that  I  have  been  always  so  scarce  of  news  to  give  you  that  I  could 
never  make  up  my  mind  to  sit  down  and  write ;  indeed,  I  cannot  say  that  I  have 
anything  to  say  at  present.  I  was  out  on  Saturday  seeing  Signer  Bosco's  magical 
entertainment  in  the  Masonic  Hall.  I  think  I  will  just  tell  you  all  my  ideas  about 
the  people  here,  as  I  do  not  think  that  they  are  fancies  of  my  own.  Old  Captain  G., 
surgeon  of  Uncle  T.'s  dragoon  regiment,  is  here;  he  calls  himself  Dr.  S.,  but  I  don't 
mind  that. 

"  Sir  J.  H.  is  here  too,  calling  himself  J.  S.  '  With  frisking  airs  Miss  pussy  tries 
the  power  of  she's  gooseberry  eyes  to  win  the  heart  of  every  swain.'  He  is  attendant 
on  a  Mr.  Y.,  whom  I  have  no  reason  to  doubt  now  is  a  brother  of  the  operatic  singer 
that  the  Duke  of  Cambridge  shot  in  the  theatre  in  Vienna.  I  am  positive  that  I  saw 
Sir  A.  in  the  Meadows  without  his  case  of  false  teeth.  Emperor  Yea  of  China  is  here 
too,  calls  himself  Mr.  B. ;  he  is  kept  by  a  son  of  Lord  C.  Peter  D.  is  head  gardener 
here ;  he,  his  wife  and  family  live  at  the  lodge  at  the  gate  on  the  road  out  to  Comiston. 
6.  D.  is  here  on  the  ground  flat ;  1  think,  when  I  recollect  right,  you  put  that  idea 
into  my  head  out  at  P.  He  is  attended  by  Malcolm,  a  son  of  Abraham  Lincoln's. 
He  writes  squibs  in  the  papers  about  the  '  Solo '  royal  familj'.  He  gets  the  papers 
printed  over  at  the  asylum  press  for  my  use,  but  I  never  read  them.  Maggie  F.'s 
brother  is  also  one  of  the  attendants  here.  Bell,  the  brother  of  the  Private  Bell  of  the 
6th  D.  G.,  is  here  acting  as  general  scogey.  He  is  the  man  that  J.  bought  Wasp 
from.  The  matron  of  the  East  House  here  is  a  sister  of  my  attendant's ;  they  are 
both  children  of  Lord  C,  and  their  mother  is  the  cook  to  the  East  House.  Abraham 
Lincoln's  wife  is  here,  kept  by  Miss  D.  Wilkes  Booth  and  Miss  Keynolds,  Gregory, 
Mag  Wallace  and  old  Armstrong  son  is  head  attendant  of  the  male  wing,  East 
House. 

"  Kind  love  to  you  all,  and  I  remain,  my  dear  edie, 

"  Your  most  aifec.  son,  "  D.  A.  O." 

"Am  I  in  a  trance  again  when  I  say  that  you  really  cooked  and  eat  the  meat  which 
came  oflT  my  head  ?" 


192  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

But  to  return  to  D.  N.,  who  may  be  taken  as  a  typical  case  of  mono- 
mania of  grandeur,  his  mind  is  not  only  affected  by  the  delusion  that  he 
is  king,  but  it  is  affected  by  an  unreal  tendency  to  elevation  in  all  direc- 
tions, and  it  is  also  now  somewhat  enfeebled,  as  is  commonly  the  case 
after  many  years  in  such  cases.  He  often  writes  me  long  rambling 
letters,  proposing  various  impractical  modes  of  managing  the  asylum,  and 
he  is  the  greatest  fault-finder  in  it.  Then  affectively  he  is  different  from 
a  sane  man,  showing  small  love  for  his  wife  or  children,  and  he  takes 
morbid  dislikes  to  people  without  real  cause.  He  once  went  down  to 
Leith  to  see  his  family,  and  went  to  all  the  houses  of  a  certain  street 
which  he  imagined  belonged  to  him,  and  gave  the  inhabitants  due  notice 
to  quit  at  the  next  term.  He  is,  of  course,  very  inconsistent  to  work  as 
a  blacksmith,  he  being  a  king ;  but  the  conduct  of  by  far  the  majority  of 
the  insane  is  quite  inconsistent  with  their  beliefs  ;  and  then  if  he  did  not 
work,  he  would  get  no  tobacco  or  beer  to  lunch,  arguments  that  even 
royalty  can  appreciate.  Sometimes  the  kings  and  cases  of  monomania 
of  grandeur  will  not  occupy  themselves  in  common  occupations.  I  have 
a  "  prophet  of  the  Lord,"  D.  0.  B.,  a  joiner,  who  by  no  means  at  our 
disposal  can  be  got  to  work  at  his  trade.  He  says  that  the  Lord  has 
sent  him  a  new  work,  and  he  must  follow  it.  He  sees  visions  from  God 
all  the  time,  which  he  puts  down  on  paper,  green  and  blue  angels,  sapphire 
prophets,  etc.  He  will  go  to  no  amusements,  or  to  church.  I  have 
another  man,  D.  0.  C,  with  almost  precisely  the  same  delusion — viz., 
that  he  is  a  "  man  of  God  " — who  is  a  capital  worker  in  the  garden,  and 
enjoys  a  dance  or  a  concert  immensely.  The  mental  disease  in  D.  N. 
was  first  seen  thirty-four  years  ago  in  an  attack  of  melancholia  from 
which  he  recovered  in  four  weeks,  and  the  present  attack  began  twenty- 
nine  years  ago,  also  with  an  attack  of  melancholia,  which,  as  it  passed 
away,  left  him  in  his  present  condition.  There  is  a  strong  heredity  to 
insanity  in  his  family,  his  brother  having  been  a  melancholic  and  com- 
mitted suicide,  and  his  eldest  daughter,  D.  0.  D.,  has  been  a  patient  here 
since  she  was  twenty-two,  being  now  a  case  also  of  monomania  of  grandeur, 
and  believing  herself  to  be  a  princess  ;  and  her  insanity  began  with  melan- 
cholia. She  is  like  her  father,  but  was  begotten  when  he  was  sane,  when 
therefore  his  disease  was  with  him  a  mere  potentiality.  But  this  is  often 
seen.  That  law  of  neurotic  heredity  through  which  in  each  successive 
generation  the  neurosis  appears  at  an  earlier  age  than  in  the  preceding 
one  was  exemplified  in  this  case,  for  the  father  was  thirty-three  Avhen  he 
first  became  insane,  the  brother,  who  committed  suicide,  thirty-two,  while 
the  daughter  was  only  twenty-two.  The  tendency  towards  early  dementia 
that  is  usually  seen  in  such  strongly  hereditary  cases  if  they  do  not  re- 
cover, is  shown  here,  for  along  with  her  delusional  condition  she  is  also 
much  more  mentally  enfeebled  than  her  father,  not  being  able  to  employ 
herself,  not  taking  interest  in  anything,  and  having  no  mental  vigor  or 
spontaneity. 

In  addition  to  the  cases  I  have  mentioned,  I  am  able  to  present  to  you 
some  of  the  most  remarkable  personages  that  have  ever  lived.  Here  is 
Jesus  Christ,  and  here  are  the  Prophet  Elias,  the  Emperor  of  the  Uni- 
verse, the  Universal  Empress,  Empress  of  Turkey,  the  only  daughter  of 
God  Almighty,  Queen  Elizabeth,  four  kings  of  England,  one  king  of 


STATES    OF    FIXED    AXD    LIMITED    DELUSION.  193 

Scotland,  the  Duke  of  Kilmarnock,  the  inventor  of  perpetual  motion,  a 
man  who  has  discovered  the  "  new  elixir  of  life  "  that  can  cure  delusions, 
twelve  persons  to  whom  this  establishment  and  all  that  it  contains  belongs, 
a  lady  Avho  daily  and  nightly  has  delightful  conversations  with  the  Prince 
of  Wales  and  the  rest  of  the  royal  family,  a  man  who  is  to  renovate 
humanity,  and  cure  all  our  existing  ills  by  means  of  a  scheme  he  has  in 
his  head.  The  gentleman  who  has  discovered  the  "new  elixir  of  life" 
wrote  out  an  advertisement  setting  forth  its  infallible  virtues  that  would 
have  done  credit  to  the  most  successful  patent  medicine  proprietor.  He 
used  to  make  it  up  in  the  asylum,  and  wanted  much  to  try  it  on  the 
patients,  but  none  of  them  believed  in  him  or  would  take  his  nostrum. 
But  he  was  allowed  to  go  out  for  a  walk  into  town  occasionally,  being  a 
harmless  man,  and  I  found  that  he  used  to  take  a  few  of  his  bottles  with 
him,  and  sometimes  sold  them  at  five  shillings  apiece — this  monomaniac 
— to  sane  citizens  of  Edinburgh  ! 

Those  are  all  calm  and  harmless  people,  some  of  them  bearing  them- 
selves in  their  deportment  and  manner  as  become  such  distinguished 
personages,  though  a  few  do  not  exhibit  any  outward  or  muscular  indica- 
tions of  their  greatness,  all  in  some  way  inconsistent,  and  absolutely  un- 
moved by  the  most  conclusive  argument  or  evidence  that  their  ideas  are 
wrong  and  unfounded.  They  all  looked  on  me  as  the  fool  to  be  pitied  or 
contemned,  who  could  not  see  their  greatness.  They  were  all  in  good 
bodily  health,  and  all  looked  as  if  they  would  live  as  long  as  any  of  us. 

In  considering  the  origin  of  this  form  of  mental  aberration,  we  see  that 
all  this  imaginary  grandeur  and  power  has  a  physiological  foundation  in 
the  brain-working  of  every  man.  The  wildest  of  these  beliefs  are  not 
half  as  extravagant  as  the  day-dreams,  imaginations,  fancies,  castles  built 
in  air,  and  longings  of  nearly  every  man  and  woman.  And  in  comparison 
to  the  imaginings  or  even  the  beliefs  of  a  child,  they  are  tame.  Compared 
Avith  the  dreams  of  most  men,  they  are  very  reasonable  indeed.  It  is  very 
easy  to  conceive  how  the  brain  of  a  man  with  a  heredity  to  insanity,  of 
unstable  constitution,  of  a  proud  imaginative  disposition,  would,  when  it 
became  disordered  in  working  from  any  cause,  readily  play  its  owner  the 
trick  of  making  him  believe  his  day-dreams  and  longings  to  be  realities. 
Once  impair  the  judging  power  that  enables  us  to  compare  and  estimate 
facts,  and  we  should  all  be  kings  or  very  great  men  at  once. 

Sometimes  the  monomania  of  grandeur  is  combined  with  that  of  sus- 
picion and  persecution.  ' 

MoNOMAXiA  OF  UxSEEN  Agency. — Another  marked  type  of  delu- 
sional insanity  is  that  of  unseen  agency.  Such  patients  believe  that 
they  are  electrified,  that  they  are  mesmerized,  that  noxious  gases  are 
blown  into  their  bedrooms,  that  people  speak  to  them  and  call  them  bad 
names  through  walls  by  telephones  and  out  of  the  ground,  that  spirits 
and  devils  haunt  them,  that  persons  come  to  them  at  night  and  break 
their  bones  or  ravish  them,  that  persons  read  their  thoughts,  or  have 
power  over  them  to  act  on  their  thoughts.  Most  of  those  delusions  im- 
ply a  sense  of  ill-being  on  the  .part  of  their  subjects,  or  pain  or  discom- 
fort, the  origin  of  which  the  patients  misinterpret.  I  had  a  woman  who 
for  long  believed  the  devil  was  inside  her.  At  the  point  where  she  said 
he  was,  I  discovered  a  cancerous  tumor,  of  which  she  died  in  a  few 

13 


194  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

months.  This  was  merely  assigning  an  insane  and  impossible  cause  for 
a  real  pain  which  she  felt.  Such  cases  are  common.  One  of  the  most 
typical  examples  of  delusions  of  being  affected  by  electricity — and  this 
and  mesmerism  are  the  two  most  common  of  all  unseen  agencies  of  which 
the  insane  complain — was  that  of  a  woman,  D.  0.  E.,  Avho,  at  sixty-four, 
became  possessed  with  the  delusion  that  people  were  electrifying  her  at 
night.  This  idea  came  on  gradually,  with  a  little  depression  at  first, 
until  it  made  her  life  an  evident  burden  to  her,  unfitted  her  for  all  work, 
and  she  accused  her  neighbors  of  "  working  the  electricity  "  on  her  when 
she  was  sent  to  the  asylum.  We  found  she  had  had  heart  disease,  ac- 
companied evidently  by  angina.  The  pain  of  this  she  attributed  to  people 
electrifying  her.  This  continued,  and  got  worse,  till  her  death  from  the 
heart  disease.  In  her  dying  moments  she  accused  us  of  causing  all  her 
pain  by  the  electricity,  and  affirmed  that  this  was  killing  her.  I  have  a 
case  now  with  "a  big  serpent  inside,"  in  which  the  delusion  originates  in 
angina.  It  is  more  common  to  have  delusions,  and  not  to  be  able  to 
trace  out  such  obvious  causes  as  those  two  cases.  All  constitutional  affec- 
tions, such  as  cancer,  tuberculosis,  rheumatism,  alcoholism,  and  especially 
syphilis,  which  cause  brain  ansemia,  and  local  disturbances  and  pains, 
may,  in  a  person  whose  brain  is  predisposed  to  mental  disturbance,  cause 
delusions  of  unseen  agency.  Dr.  Hugh  G.  Stewart  long  ago  described 
certain  syphilitic  cases  who  imagined  that  noxious  gases  were  blown  into 
their  rooms  at  night,  or  driven  into  their  nostrils.  To  prevent  this  they 
stopped  the  keyholes  of  their  doors  at  night,  plugged  their  nostrils  and 
ears,  wrapped  their  heads  up.  I  have  met  with  many  such  patients.  It 
is  evident  that  there  is  a  general  sense  of  organic  discomfort  in  such  men, 
which  is  misinterpreted  into  those  delusions.  Frequently  the  chronic 
irritation  of  the  drunkard's  stomach  is  attributed  by  him  to  living  ani- 
mals inside,  or  to  poison.  I  once  had  a  patient,  D.  P.,  who  had  been  a 
great  drunkard,  and  had  had  many  attacks  of  acute  alcoholism,  who  said 
he  had  mice  inside  him,  gnawing  and  running  about.  He  was  gradually 
cured  or  recovered  in  about  two  years,  under  a  teetotal  regimen,  bismuth, 
easily  digested  food,  and  fresh  air.  I  give  here  the  letter  of  a  syphilitic 
case,  D.  Q. : 

"Forced  dreaming,  forced  vomiting  from  the  stomach,  forced  ghit  vomiting  from 
the  throat,  cold  shivering  by  the  forced  thinking,  sweating  done  in  the  same  way, 
pains  in  the  stomach  any  way  they  think.  I  think  it  is  time  that  this  way  of  pun- 
ishing should  be  stopped,  and  let  me  know  if  there  is  anything  going  to  be  done  for 
my  benefit;  and  I  want  to  see  about  bad  usage.  I  think  it  was  lime  it  was  stopped, 
I  would  thank  you  to  let  me  know  the  real  truth. — I  am,  &c." 

This  man  was  an  old  soldier,  and  had  on  admission  all  the  appearance 
of  the  syphilitic  cachexia.  He  used  to  talk  constantly  about  his  delu- 
sions, and  be  rather  dangerous,  but  now,  after  five  years,  he  never  men- 
tions them  except  he  is  spoken  to  about  them,  and  in  fact  scarcely  speaks 
:at  all.  His  bodily  health  is  much  improved,  and  he  works  in  the  garden 
every  day.  The  following  letter  was  written  to  me  by  a  man,  D.  R., 
who  was  very  dangerous  indeed  from  his  delusions,  often  threatening  to 
kill  me,  and,  he  afterwards  said,  often  seriously  deliberating  whether  he 
would  do  so  or  not : 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  195 

"Ut  April,  1868. 

"  Mr.  Cloltston, — I  now  take  the  opportunity  of  writing  you  these  few  lines  to 

let  yon  know  that  I  am  quite  well  in  health,  but  you  have  punished  me  sore,  and  I 

do  not  know  what  it  is  for.     A  week  or  two  after  I  came  here  you  let  me  alone,  and 

then  you  started  and  did  wrong  with  me,  and  all  your  attendants  had  some  stuff"  to 

stifle  me  with.     I  think  it  is  a  disgraceful  affair,  and  John very  nearly  choked 

me.     Some,  too,  at  the  table,  for  I  think  you  have  them  put  on  to  do  so,  and  in  the 

bedroom  there  is  Adam ,  for  I  have  catched  him,  and  told  him  about  it.     On  the 

18th  of  February  you  crushed  my  breast,  and  on  the  20th  you  crushed  m}'  left  side  in. 
I  thought  you  liad  done  for  me,  and  on  the  21st  February  you  crushed  the  right  side 
in.  And  the  curious  conversations  you  have  been  making  with  me  at  nights.  It's  a 
shame  and  a  disgrace.  You  ought  not  to  try  to  kill  me  altogether.  I  have  stood 
bad  treatment  that  would  have  killed  ten  men,  and  you  ought  to  put  a  stop  to  it,  for 
I  have  done  no  wrong,  &c." 

This  man  seemed  in  perfect  bodily  health,  and  I  could  not  discover 
any  peripheral  causes  for  the  painful  sensations  he  probably  had,  and 
which  lie  so  misinterpreted.  But  in  every  case  I  advise  you  to  examine 
carefully  into  the  condition  and  working  of  the  great  organs  and  func- 
tions, and  the  history  of  the  patient,  to  find  out  Avhether  there  has  been 
syphilis  or  rheumatism,  or  other  constitutional  disorder.  Such  delusions 
of  unseen  agency  are  often  associated  with  hallucinations  of  hearing. 
Patients  fancy  that  people  whisper  through  floors,  and  down  chimneys. 
One  patient  I  had  was  tormented  by  people  speaking  down  the  chimney, 
another  was  constantly  annoyed  by  people  talking  to  him  through  tele- 
phones, and  a  man  who  had  been  a  heavy  drinker,  and  had  acute  alco- 
holism several  times,  said  he  was  constantly  subjected  to  a  process  which 
he  called  "ric-me-tic."  That  persons  read  their  thoughts  and  influence 
their  thoughts  are  very  current  delusions.  Patients  almost  always  com- 
plain most  of  unseen  agencies  at  night,  just  as  they  have  hallucinations 
most  at  nights,  when  there  are  no  conflicting  real  impressions  on  the 
senses.  It  is  very  common  for  women  to  have  the  delusion  that  they  are 
made  insensible,  and  ravished  at  nights.  One  can,  of  course,  more 
readily  understand  the  explanation  of  such  delusions  than  of  others. 

I  am  told  it  is  very  common,  indeed,  for  criminals  undergoing  solitary 
confinement  in  penal  servitude  to  have  delusions  that  they  are  worked  on 
by  electric  batteries.  Their  weak  degenerate  brains,  natural  suspicions, 
ignorance,  and  the  occasional  use  of  the  electric  battery  to  detect  impos- 
ture among  them,  seem  to  account  for  this.  I  once  had  such  a  man  sent 
from  Broadmoor  Criminal  Asylum  to  the  Carlisle  Asylum  at  the  expira- 
tion of  his  sentence,  a  strong  bad-looking,  dangerous  fellow,  whom  we 
regarded  as  the  worst  man  in  the  place.  After  a  few  months  he  escaped, 
and  after  being  in  hiding  among  his  friends  for  a  short  time,  began  to 
work,  and  has  remained  an  industrious,  self-supporting  member  of  society 
ever  since,  and  that  after  having  been  for  years  regarded  as  a  most  dan- 
gerous criminal  lunatic.  No  doubt,  having  first  to  secure  his  safety  from 
recapture  and  then  to  earn  his  own  living,  and  being  away  from  those 
whom  he  would  consider  his  natural  enemies,  his  mind  would  be  dis- 
tracted from  his  delusion,  and  it  would  cease  to  have  its  former  power 
over  him  to  influence  his  conduct. 

In  some  few  cases  delusions  of  unseen  agency  are  pleasant  to  the  pa- 
tient, or  at  all  events  are  not  complained  of.  Some  of  the  sexual  cases 
are  of  this  character.     Such  was  the  case  in  the  man  D.  S.,  who  wrote 


196  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

me  this  letter :     '■'' Record  of  Miracles^ — The  Reverend came 

to  see  me,  and  his  countenance  changed  to  that  of  my  deceased  uncle 

.     My  length  while  in  bed  was  increased  to  about  seven  feet, 

and  then  made  normal.  When  in  bed  a  very  pretty  colored  landscape, 
including  cottage  and  woman  at  her  washing-tub,  appeared  on  the  wall. 
The  picture  could  not  have  been  produced  by  the  aid  of  the  camera. 
P.  Smith,  casting  a  wry  look  at  me,  jumped  from  the  floor  to  a  height  of 
a  foot,  then  passed  through  a  framed  picture  without  injury  thereto,  and 
through  a  solid  fourteen-inch  stone  wall,  then  came  through  the  water- 
closet  door  to  meet  me.  While  peering  in  at  the  laundry  windows  a 
number  of  the  girls'  clothes  flew  oft"  them  while  at  their  washing-tubs,  and 
after  about  half  a  minute's  nakedness  their  clothes  came  back  to  them, 
and  they  were  properly  fastened  without  their  aid.  Near  Myreside  Cot- 
tage, James  S.,  astride  a  thin  wire  fence,  was  seen  speeding  along  for 
about  one  hundred  yards,  the  wooden  posts  forming  no  impediment  to 
his  'Aviremanship,'  &c." 

I  have  under  my  care  at  present  a  gentleman,  D.  T.,  who  believes  he 
is  under  the  power  of  "  an  automaton,"  which  controls  him,  makes  him 
scream  out,  talk  nonsense,  break  dishes,  etc.  He  is  a  quiet  and  most 
courteous  gentleman,  who,  after  having  done  one  of  those  things,  will 
reply,  if  asked  why  he  behaved  so,  in  a  peculiarly  measured  calm  manner 
— "  The  automaton  made  me  do  it.  I  did  not  wish  to  do  anything  of  the 
sort."  He  will  say  sometimes,  still  more  calmly,  "  Will  you  write  to  the 
commissioners  to  remove  the  automaton  ?"  "I  beg  to  renew  my  request 
of  the  14th  of  July." 

Monomania  of  Suspicion. — The  third  great  class  of  delusional  cases 
are  those  of  suspicion  and  persecution.  This  kind  of  delusional  condition 
is  essentially  the  same  as  the  last,  only  it  is  not  so  great  a  departure  from 
soundness  of  mind,  but  for  convenience  sake  we  separate  them.  Patients 
who  labor  under  this  form  of  mental  disease  do  not  attribute  their  annoy- 
ances to  unnatural,  unseen,  or  impossible  means,  but  to  the  malevolence 
of  real  persons  who  plot  against  them,  have  evil  designs  on  them,  poison 
their  food,  annoy  them,  persecute  them,  prove  unfaithful  to  their  marriage 
vows,  etc.  We  all  know  that  the  natural  development  of  suspicion  is  very 
various  in  different  people.  Many  people  are  of  a  suspicious  temperament 
from  the  beginning,  others  are  made  suspicious  by  real  experiences  in  life 
or  by  ill  health.  We  know  that  the  weak  are  always  suspicious  through- 
out the  whole  of  the  animal  kingdom.  It  is  the  same  with  human  brains. 
An  element  of  morbid  suspicion  exists  at  the  beginning  of  nearly  all 
cases  of  melancholia.  Nothing  is  more  common  than  for  such  persons  to 
imagine  that  people  are  looking  at  them,  watching  them,  and  following 
them  about.  I  look  on  this  as  mental  evidence  of  an  ill-nourished  or 
anaemic  brain.  But  in  the  class  of  persons  of  whom  I  am  to  speak  it  is 
a  chronic  manifestation  of  a  disordered  brain.  As  we  shall  see  when  I 
come  to  talk  of  phthisical  insanity,  morbid  suspicion  is  the  most  constant 
sign  of  the  brain  malnutrition  that  goes  with  a  combination  of  a  heredity 
to  tuberculosis  and  to  insanity.  A  man,  D.  T.  A.,  who  is  a  patient  of 
mine,  is  full  of  suspicions  about  everyone  near  him.  He  thinks  that 
everyone  about  annoys  him  on  purpose.  If  another  patient  coughs,  it  is 
to  annoy  him ;  if  one  spits,  it  is  to  insult  him ;  if  one  sings,  the  words 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  197 

refer  to  him.  His  career  is  instructive.  He  was  a  soldier,  and  lived 
hard,  had  an  attack  of  acute  mania,  and  when  the  exaltation  and  excite- 
ment passed  off,  he  Avas  left  in  his  present  condition,  and  has  remained 
so  for  twenty-one  years.  For  the  first  thirteen  years  he  was  regarded  as 
a  dangerous  man,  and  it  was  feared  to  put  any  sort  of  tool  or  instrument 
into  his  hand,  for  he  was  the  hero  of  many  fights — in  fact,  fought  or 
wanted  to  fight  some  one  every  day.  But  as  he  was  a  tinsmith  originally, 
and  I  found  him  one  day  in  a  better  humor  than  usual,  I  sent  him  to  the 
tinsmith  shop  of  the  asylum,  not  without  fears  that  he  might  murder 
some  one.  He  had  just  before  written  this  letter :  "  I  write  to  you  to 
let  you  know  that  I  am  much  abused  here  by  villains.  I  will  be  clear 
of  the  band  of  villains  they  have  upon  me.  Be  so  good  as  come  before 
they  kill  me.  I  am  not  able  to  stand  death  here.  They  have  poisoned 
me  many  a  time.  I  will  not  stand  the  bloody  abuse  that  they  are  giving 
me.  A  fellow  they  call  Hamilton  [a  fellow-patient  who  talked  to  himself] 
is  abusing  me  most  awfully,"  etc.  With  much  tobacco  and  a  little  beer, 
of  which  he  was  very  found,  and  many  promises  that  all  the  "  villany  " 
would  be  ended  if  he  would  work  well  and  not  fight,  we  set  him  to  work. 
He  took  to  it  at  once,  worked  as  if  his  life  depended  on  it,  hammered 
away  at  tin  and  copper  plates,  making  them  into  utensils,  and  evidently 
found  much  satisfaction  in  the  outlet  that  unlimited  hammering  and  much 
noise  gave  him  for  his  muscular  energy  and  irritated  feelings.  He  clearly 
treated  the  tin  plates  as  if  they  were  the  "  villains  "  that  had  been  annoying 
him.  The  great  difficulty  was  to  provide  him  work  enough,  he  got  through 
it  so  quickly.  From  that  day  to  this,  now  eight  years,  he  has  been  one 
of  the  most  useful  members  of  our  community.  If  he  has  a  fight,  it  is 
usually  on  Sunday.  He  still  has  the  delusions  of  suspicion,  but  they  are 
not  all-powerful  in  his  mind  as  they  were,  and  his  countenance  is  less 
expressive  of  fierce  passion.  He  has  got  to  believe  now  he  has  some 
friends,  and  that  mollifies  him. 

Patients  in  this  condition  of  morbid  suspicion  attach  delusional  impor- 
tance to  simple  acts,  e.  g.,  a  man  who  got  some  porter  for  his  health  wrote 
me  the  following  letter :  "  Sir,  I  find  by  the  report  printed  in  the  papers 
that  you  date  your  appointment  as  physician-superintendent  here  on  the 
first  day  of  Aug.  1873.  Who  then  justified  my  porter  test?"  He  im- 
agined that  I  was  testing  his  mental  state  by  the  porter.  I  had  a  clergy- 
man once,  D.  T.  B.,  under  my  care,  who  fancied  that  a  conspiracy  had 
been  got  up  against  him  to  put  him  out  of  every  curacy  he  had  held, 
and  to  prevent  him  getting  a  living,  that  the  bishop  had  been  concerned 
in  this,  and  of  course  magistrates  and  authorities  had  refused  him  redress. 
Here  is  part  of  a  letter  of  his :  "  My  dear  Dr.  Clouston,  I  have  oftener 
than  once  heard  of  your  welfare,  which  I  hope  will  go  on  prosperously 
80  long  as  you  are  the  true  and  faithful  servant  of  God,  though  no  further, 
as  I  told  you.  My  state  of  outrage  and  ivrong  you  know  well  or  better 
than  I  do,  for  all  to  me  is  a  complete  mystery  beyond  what  I  do  i*eally 
know  and  have  been  compelled  to  feel.  In  places  of  this  kind  there  is 
so  much  '  pantomime,'  so  I  pay  no  attention  to  such  nonsense.  I  have 
received  no  redress  or  improvement  whatever ! !  What  part  you  have 
taken  in  the  wrong  I  am  suflFering  you  hnoiv.  There  are  and  have  been 
several  nice  vacancies,  one  of  which  will  suit  me,  though  any  part  of 


198  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

England,  so  as  to  be  far  oiF  the  atmosphere  of  asylums,  will  suit  me.  I 
am  in  constant  expectation  of  ''freedom,'  '' com-pcnsation,'  and  a  '•benefice' 
of  my  own.  I  have  merit  and  purity  enough  for  a  bishop" — and  so  on 
for  many  pages  of  complaint  and  morbid  suspicion.  By  the  way,  you 
will  notice  that  he  underlines  much  of  his  letter.  The  late  Sir  Robert 
Christison  once  said  to  me  that  he  could  usually  tell  a  man  Avho  labored 
under  insane  delusions  by  the  way  he  unnecessarily  underlined  his  letters, 
and  there  is  much  truth  in  the  observation. 

The  most  painful  of  all  the  cases  of  delusions  of  suspicion  are  those 
where  a  husband  becomes  insanely  jealous  of  his  wife,  and  suspicious  of 
her  fidelity  without  reason.  After  the  full  development  of  such  a  case, 
it  is  easy  to  see  that  such  suspicions  are  insane,  by  the  exaggerated  way 
they  are  put,  and  by  the  utter  want  of  evidence  ;  but  at  the  beginning 
they  are  most  difficult  and  unpleasant.  I  have  now  a  lady  in  the  asylum, 
D.  T.  C,  quiet  in  manner,  ladylike,  and  almost  rational,  who  showed  her 
insanity  first  by  going  to  her  clergyman  and  making  a  confidential  report 
to  him  that  her  husband  had  given  her  syphilis,  and  he  was  accordingly 
at  once  summoned  for  ecclesiastical  censure  by  the  kirk-session  of  his 
church.  Being  a  sensitive,  nervous  man,  this  had  an  extraordinary 
efiect  on  him.  From  being  fond  of  his  wife,  he  suddenly  conceived  a 
hatred  of  her,  believing  that  it  was  a  deliberate  plot  to  ruin  him.  Though 
other  symptoms  of  insanity  developed  themselves  in  her,  he  never  to  his 
dying  day  could  be  made  to  believe  that  the  syphilis  delusion  was  any 
symptom  of  insanity  on  her  part,  but  looked  on  it  as  simply  wickedness. 
In  her  case  the  nature  of  her  delusion  seemed  to  be  deteraiined  by  the 
fact  that  she  had  a  chronic  uterine  tumor,  the  uneasy  sensations  connected 
with  which  seemed  to  have  suggested  it.  You  should  always  look  for 
bodily  causes  of  delusions.  I  was  once  sent  for  in  great  haste,  as  a 
geentleman,  D.  T.  D.,  was  said  to  be  killing  his  wife.  I  found  a  most 
respectable  man,  of  first-rate  business  capacity,  who  had  made  a  large 
fortune,  and  was  still  doing  business,  and  who  was  reputed  by  the  world 
at  large  to  be  perfectly  sane,  making  the  most  outrageous  allegations 
about  his  wife,  and  saying  she  had  been  unfaithful  to  him.  I  soon  found 
that  those  accusations  were  of  necessity  insane  delusions.  He  had  seen 
her  wink  to  scavengers  as  she  passed  them.  He  had  met  her  just  parted 
from  a  laboring  man,  with  whom  she  had  had  connection  under  a  wall,  etc. 
I  have  now  in  the  asylum  two  quiet,  rational-loooking  men,  whose  chief 
delusion  is  that  their  wives,  both  women  of  undoubted  good  character, 
have  been  unfaithful  to  them.  Keep  them  off  that  and  they  are  rational. 
On  that  subject  they  are  utterly  delusional  and  insane.  They,  like  most 
such  cases,  are  incurable. 

As  an  example  of  a  perverted  sensation  or  a  local  pain  causing  a 
delusion,  I  have  now  a  gentleman,  D.  T.  E.,  with  disease  of  the  rectum, 
who  maintains  that  people  come  at  night  and  commit  sodomy. 

It  is  not  uncommon  to  find  women  of  middle-life  with  the  combined 
delusions  that  certain  men  want  to  marry  them,  but  that  other  people  are 
preventing  this.  Clergymen  are  the  most  frequent  objects  of  this  most 
undesirable  fancy.  I  have  met  with  at  least  a  dozen  cases  in  all  ranks  of 
life  of  this  kind.  The  subjects  of  it  are  usually  not  marriageable 
or  attractive-looking  persons.     I  shall  show  you  a  one-legged  dressmaker 


STATES    OF    FIXED    AXD    LIMITED    DELUSION.  199 

of  forty,  D.  T.  F.,  with  certainly  no  personal  charms,  who  went  to  her 

clergyman  and  asked  him  to  "proclaim"  her  and  Mr. in  church. 

On  inquiry,  he  found  the  gentleman  to  be  proclaimed  had  never  spoken 
to  her.  He  sat  opposite  to  her  in  church,  and  she  said  he  looked  at  her 
in  such  a  significant  way  that  she  knew  he  wanted  their  banns  proclaimed. 
D.  T.  F.  said  it  was  all  owing  to  a  scheming  neighbor  that  she  was  not 
married  to  INIr. . 

A  morbid  feeling  of  fear  is  often  associated  with  that  of  suspicion, 
especially  in  the  cases  that  have  arisen  out  of  melancholia.  I  have 
a  patient  who  is  afraid  if  I  take  out  my  handkerchief,  that  it  means 
something  evil  towards  herself,  who  is  constantly  saying  "Now,  doctor,  I 
know  you  are  going  to  do  something  to  me,  what  is  it  to  be?" 

It  is  common  for  patients  with  monamania  of  suspicion  to  conceal  their 
delusions,  except  to  intimate  friends  or  near  relations,  for  a  long  time, 
even  for  years,  and  Avhen  asked  about  them  to  deny  that  they  believe 
them.  We  had  a  gentleman  in  Morningside  (D.  T.  G.)  once,  who  was 
full  of  morbid  suspicions,  believing  that  some  of  the  people  about  him 
were  other  persons  altogether,  and  that  he  was  at  times  in  danger  of  his 
life  from  poison.  Yet  for  many  years  he  never  told  these  things  to  any 
person  but  one  fellow-patient.  Unlike  the  majority  of  such  cases,  he 
was  to  most  persons  a  pleasant  man ;  his  social  instincts  were  strong,  he 
was  fairly  happy,  going  all  about  the  country  on  fishing  excursions,  and 
enjoying  a  joke  and  good  story  immensely.  Before  his  death,  when  his 
brain  disease  had  advanced,  he  was  not  so  reticent  about  his  delusions.  I 
have  now  two  patients,  D.  T.  H.  and  D.  T.  I.,  who  on  their  first  admis- 
sions I  had  to  discharge,  because  they  denied  their  delusions  so  strenu- 
ously. In  fact,  D.  T.  H.  was  twice  discharged  for  that  reason.  Yet 
they  both  labored  under  most  insane  suspicions,  that  the  people  in  their 
houses  and  the  streets  annoyed  them,  and  wanted  to  kill  them.  When- 
ever D.  T.  H.  got  a  glass  of  whiskey,  these  delusions  at  once  came  out. 
On  one  occasion  the  second  medical  certificate  for  his  admission  could  not 
be  got,  and  he  was  tried  before  the  Sheriff  for  threatening  language.  I 
had  to  say  that  I  believed  him  to  be  insane,  but  that  I  had  no  proofs  of  it 
from  himself.  That  was  deemed  sufficient,  and  he  was  committed  to  the 
asylum.  I  have  another  patient  who  has  been  four  times  in  an  asylum, 
and  while  there,  has  never  uttered  one  insane  suspicion,  though  full  of 
these  about  his  wife,  and  really  most  dangerous  to  her. 

There  are  cases  of  monomania  not  to  be  classified  under  those  three 
headings.  I  have,  for  instance,  a  man  in  the  asylum,  D.  T.  K.,  who  for 
ten  years  has  never  spoken  a  word,  but  who  I  may  say  in  all  other 
respects  behaves  sanely,  showing  no  symptoms  of  morbid  pride  or 
suspicion.  He  is  about  the  best  joiner  we  have.  We  know  he  has 
a  delusion  which  prevents  him  speaking,  but  what  it  is  we  can't  find  out. 
If  he  wants  instructions  about  his  work,  he  writes,  but  nothing  will 
induce  him  to  write  why  he  won't  speak.  There  ai'e  certain  patients,  too, 
who  simply  express  delusions  as  to  the  identity  of  those  about  them, 
without  any  suspicious,  fearful,  or  persecuted  feeling.  There  is,  indeed, 
a  great  variety  in  the  symptoms  of  those  who  labor  under  delusional 
insanity. 


200  STATES    OF    FIXED    AND    LIMITED    DELUSION. 

Proportion  of  Cases  of  Monomania. — At  the  close  of  the  year 
1881,  there  were  eight  hundred  and  twenty-two  patients  of  all  classes  in 
the  Royal  Edinburgh  Asylum,  and  of  these  eighty-seven  were  cases  of 
delusional  insanity,  viz. :  thirty-five  of  grandeur,  fourteen  of  unseen 
agency,  and  thirty-eight  of  suspicion.  Of  the  eighty-seven,  forty-eight 
were  men  out  of  the  four  hundred  and  twenty -one  male  patients,  so  that 
the  proportion  in  the  two  sexes  did  not  differ  much.  There  were  more 
cases  of  monomania  of  pride  and  grandeur  among  the  women  than  among 
the  men,  twenty  to  fifteen;  while  of  suspicion  there  were  twenty-five 
among  the  men  to  only  thirteen  among  the  women.  I  found  one  marked 
phenomenon  in  the  natural  history  of  delusional  insanity.  Out  of  one 
hundred  and  twenty  patients  of  the  higher  classes  socially,  all  with  edu- 
cated brains,  and  many  of  them  of  old  families,  there  were  twenty-three 
cases  of  monomania,  or  about  one-fifth  of  the  whole,  while  among  the 
five  hundred  and  fifty-four  pauper  patients  there  were  only  forty -four 
cases  of  this  variety  of  mental  disease,  or  only  one-twelfth  of  the  whole. 
The  one  hundred  and  fifty-eight  private  patients  of  lower  social  class  were 
intermediate,  and  had  twenty  cases  of  monomania,  or  less  than  one-seventh. 
It  would  seem,  therefore,  that  delusional  insanity  is  most  apt  to  occur  in 
brains  of  the  highest  education. 

Diagnosis  of  Monomania. — I  had  a  woman  sent  into  the  asylum 
lately  who  told  me  she  was  the  mother  of  God.  We  had  no  history  of 
the  case  at  all.  There  was  no  general  exaltation,  no  excitement,  and  no 
depression  apparent.  Was  not  that  a  case  of  delusional  insanity  ?  Not 
in  a  correct  use  of  the  term,  for  the  woman  gradually  passed  into  an 
attack  of  simple  mania,  ceasing  to  express  this  particular  delusion  after  a 
few  days.  Therefore,  you  must  always  take  into  account  the  fixedness  of 
the  delusion  or  the  delusional  state,  and  the  time  the  patient  has  suifered 
from  it.  Many  maniacal  and  melancholic  patients  begin  by  expressing  a 
single  delusion,  or  exhibiting  a  single  delusional  state  as  the  commence- 
ment of  their  general  disease.  I  have  met  with  plenty  of  cases,  too, 
where  from  the  very  subacuteness  of  the  mania  or  the  melancholia,  the 
symptoms  of  general  exaltation  or  depression  were  not  very  evident,  and 
a  delusion  stood  out  as  apparently  the  disease,  and  yet  the  patient  soon 
recovered.  And  as  patients  are  recovering  from  mania  and  melancholia, 
they  often  exhibit  delusional  conditions  for  a  long  time  after  the  general 
exaltation  or  depression  has  passed  ofi".  I  had  a  patient  who  had  an 
attack  of  acute  mania  lasting  for  three  months,  and  after  that,  though 
quiet,  industrious,  and  rational  on  most  subjects,  he  believed  his  food  was 
poisoned  for  twelve  months.  He  then  gradually  ceased  to  believe  his  food 
was  being  poisoned,  but  he  believed  that  it  had  been  poisoned  before  for 
twelve  months  longer.  I  classifv  such  a  case  as  one  of  acute  mania,  not 
of  monomania  of  suspicion.  By  the  way,  a  patient's  belief  in  the 
reality  of  his  former  delusions  is  not  at  all  uncommon.  A  man  says  "no 
one  annoys  me  now,  but  I  was  subjected  to  persecution  at  home  and 
when  first  I  came  into  the  asylum."  I  should  not  keep  a  man  in  ?n 
asylum,  or  count  him  a  monomaniac,  or  even  reckon  him  as  legally 
insane,  merely  because  he  believed  in  the  reality  of  his  former  delusion, 
if  he  had  ceased  to  believe  in  their  present  existence,  any  more  than 
I  should  count  a  man  insane  who  could  not  get  rid  of  the  impression  that 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  201 

the  events  of  a  dream  had  really  taken  place.  The  two  chief  things  to 
be  kept  in  mind  in  the  diagnosis  of  monomania  are :  1.  Not  to  call  any 
disease  by  that  name  that  has  not  existed  unaltered  for  at  least  twelve 
months.  2.  When  there  exists  along  Avith  the  delusional  condition  any 
general  brain  exaltation  or  excitement,  or  any  general  depression,  not  to 
call  it  by  that  name  till  those  have  passed  off. 

Origin  of  Monomania. — It  arises  in  at  least  four  different  ways  in 
different  cases.  1.  It  is  a  gradual  evolution  out  of  a  natural  disposition, 
a  proud  man  becoming  insanely  and  delusionally  proud,  a  naturally 
suspicious  man  passing  the  sane  borderland  with  his  suspicions.  From 
going  over  our  cases  I  find  about  one-fourth  of  them  arose  in  this  way. 
It  is  the  most  common  origin  of  the  disease.  There  is  usually  a 
hereditary  predisposition  to  insanity  in  those  patients.  The  disposition 
may  in  fact  be  regarded  as  the  nervous  diathesis  out  of  which  the  mental 
disease  springs.  2.  It  remains  as  a  permanent  brain  result  and  damage, 
after  attacks  of  mania  and  melancholia,  especially  the  former,  from  which 
the  patients  recover  up  to  a  certain  point,  but  no  further.  This  is  the 
origin  of  about  one-sixth  of  the  cases.  3.  It  arises  from  alcoholic  and 
syphilitic  poisoning  of  the  brain  and  body,  from  traumatic  injuries  of  the 
brain,  or  sunstroke,  or  from  gross  lesions,  such  as  embolic  sufferings. 
This  seems  to  me  to  be  its  origin  in  about  one-fifth  of  the  cases.  Such 
have  usually  the  delusional  insanity  of  suspicion  or  unseen  agency.  They 
are  the  most  dangerous  class  of  monomaniacs  on  the  whole.  4.  Most  of 
the  remainder,  comprising  over  one-third  of  the  cases,  seemed  to  me  to 
arise  either  out  of  perverted  organic  sensations  caused  by  constitutional 
diseases  characterized  by  lack  of  trophic  power  and  brain  anaamia,  notably 
tuberculosis,  or  out  of  perverted  sensations  from  local  diseases  misinter- 
preted by  the  brain,  as  in  the  woman  with  cancer  of  stomach.  As  a 
matter  of  fact,  a  very  large  proportion  of  the  cases  of  monomania  of 
suspicion  die  of  phthisis  pulmonalis.  Any  man  with  an  anaemic,  ill- 
nourished  brain,  is  apt  to  be  morbidly  suspicious. 

Legal  Importance  of  Insane  Delusions. — Delusions  are  often  of 
small  clinical  import,  but  are  always  of  the  highest  value  as  a  test  of  in- 
sanity from  the  lawyer's  point  of  view.  Therefore  I  advise  you  to  bring 
them  in  always,  if  they  exist,  in  signing  certificates  of  insanity,  in  medico- 
legal documents,  and  in  giving  evidence  before  courts  of  justice.  But 
you  must  remember  there  are  harmless  and  dangerous  delusions  ;  and  if 
a  delusion  is  obviously  harmless,  and  does  not  bulk  largely  in  the  patient's 
life  or  affect  his  conduct,  the  law  scarcely  recognizes  it  as  unsoundjiess  of 
mind  at  alL  It  is  quite  impossible  to  distinguish  scientifically  between 
some  vain  or  proud  men,  who  dress  and  behave  in  an  absurd  manner,  but 
do  nothing  needing  interference  with  their  liberty,  and  the  man  who 
thinks  himself  the  son  of  George  the  Fourth,  claims  property  that  does 
not  belong  to  him,  and  is  therefore  shut  up  in  an  asylum.  There  are 
plenty  of  persons  doing  their  work  in  the  world  well,  and  yet  they  labor 
under  monomania  of  pride  or  suspicion  in  a  mild  form.  The  now 
famous  case  of  Mr.  Wyld,  who  held  an  important  Government  office,  and 
did  his  work  well  all  his  life,  and  yet  had  labored  under  the  delusion  of 
grandeur,  that  he  was  a  son  of  George  the  Fourth,  and  left  all  his  money  , 
to  the  town  of  Brighton,  because  that  monarch  had  been  fond  of  that 


202  STATES    OF    FIXED    AND    LIMITED    DELUSION". 

place,  is  one  in  point.  He  was  held  to  be  sane  in  everything  he  did  but 
his  "will-making.  I  am  constantly  consulted  by  their  friends  about  the 
insane  delusions  of  persons  who  do  not  show  them  to  anybody  but  their 
near  relations,  and  continue  to  do  their  work  and  occupy  responsible 
positions.  I  now  know  in  Scotland  lawyers,  doctors,  clergymen,  business 
men,  and  workmen,  who  labor  under  undoubted  delusional  insanity,  and 
yet  do  their  work  about  as  well  as  if  they  had  been  quite  sane,  though 
they  are  not  such  pleasant  people  as  they  would  have  been  if  sane,  espe- 
cially to  their  relatives. 

Treatment  of  Delusional  Insanity. — At  the  bemnninor,  when 
there  is  a  chance  of  the  delusions  not  being  quite  fixed,  there  are  two 
indications  for  treatment.  The  first  is  change  of  scene,  circumstances, 
company,  and  occupation,  Avhich  can  best  be  done  by  travelling  about. 
The  mind  may  be  sometimes  diverted  from  morbid  tendencies  in  that 
way.  And  while  this  is  being  done,  the  second  indication  should  be 
carried  out,  which  is  to  correct  and  cure  bodily  disorders,  to  treat  con- 
stitutional diseases  like  tuberculosis  and  syphilis  and  annemia  by  suitable 
means,  and  to  remove  every  bodily  cause  of  convolutional  disturbance,  to 
withdraw  objects  of  suspicion,  and  to  bring  up  to  the  highest  possible 
mark  the  nervous  and  bodily  tone.  By  this  means  there  is  no  doubt  that 
some  cases,  especially  those  characterized  by  morbid  suspicion,  can  be 
cured,  even  after  they  have  existed  for  years.  I  have  even  seen  a  marked 
case  of  monomania  of  grandeur  get  better.  A  man  who  for  more  than  a 
year  fancied  himself  the  Duke  of  Kilmarnock,  got  quite  well,  through  im- 
provement in  his  bodily  health,  and  working  in  the  asylum  garden.  In 
a  few  cases  with  hallucinations  of  hearing,  the  continued  current  through 
the  brain  has  seemed  to  do  good.  But  for  the  confirmed  monomaniacs  of 
all  sorts,  who  will  insist  on  carrying  out  their  ideas,  an  asylum  is  the 
only  possible  place  of  care.  Dr.  Charles  H.  Skae  cured  a  case  of  mono- 
mania of  suspicion  caused  through  an  injury  to  the  head  by  trephining. 

Prognosis. — The  prospect  of  recovery  is  certainly  very  bad  in  cases 
of  delusional  insanity  that  have  lasted  for  over  a  year,  but  one  is  surprised 
sometimes  by  occasional  recoveries  after  many  years.  There  is  a  tendency 
to  mental  enfeeblement  as  time  goes  on.  Many  cases  end  in  complete  de- 
mentia after  a  few  years,  and  in  most  the  intensity  of  the  conviction  of 
the  delusion,  and  the  aggressiveness  with  which  it  is  put  forward,  tend 
to  diminish  as  time  goes  on.  Most  monomaniacs  live  long,  all  but  the 
cases  of  morbid  suspicion,  who,  as  I  said,  mostly  die  of  phthisis. 

Prophylaxis. — I  think  something  can  be  done  in  those  who  are  pre- 
disposed towards  delusional  insanity  by  their  nervous  diathesis  and  heredi- 
tary predisposition  to  the  neuroses  alone  or  combined  with  a  heredity  to 
consumption,  towards  counteracting  the  morbid  disposition.  While  the 
reasoning  power  still  holds  its  sway,  it  may  be  used  in  deliberate  attempts 
to  reason  a  man  out  of  his  morbid  tendencies.  I  think  I  have  seen  a  man 
in  this  way,  and  by  not  allowing  himself  to  dwell  on  morbid  thoughts  and 
feelings,  keep  in  check  a  morbid  disposition.  Good  principles  and  good 
habits  of  life  help  greatly  in  the  same  direction.  The  occupation  may 
be  helpful,  too,  in  counteracting  it.  I  have  often  seen  monomania  of 
suspicion  arise  out  of  a  suspicious,  reserved  temperament  in  young  men, 
through  the  thoughtless  and  cruel  small  persecutions  and  annoyances  of 


STATES    OF    FIXED    AND    LIMITED    DELUSION.  203 

fellow-clerks  and  fellow-workmen.  Human  nature  is  not  tender  or  con- 
siderate towards  such  weaknesses.  I  have  certainly  seen  a  proud  dis- 
position become  a  monomania  of  pride  through  the  injudicious  pamperings 
and  foolish  adulation  of  female  relations,  and  the  encouragement  of  such 
a  person  in  occupations  and  schemes  beyond  his  capacity  or  means.  No 
doubt  temperate  habits  in  all  things  are  very  prophylactic  for  the  kind 
of  brains  I  am  now  describing.  I  think  I  have  seen  cheerful  family  life 
cure  a  commencing  delusion  of  suspicion.  Association  with  their  fellow- 
men  is  good  for  all  persons  predisposed  in  this  way,  provided  they  can 
get  suitable  company  to  associate  with.  To  be  suitable,  it  needs  often  to 
be  opposite  and  complimental.  In  all  persons  predisposed  to  delusional 
insanity,  the  social  instincts  are  apt  to  be  rudimentary,  and  need  develop- 
ment. There  is  no  class  of  the  insane  who,  on  the  whole,  show  their 
morbid  tendencies  at  an  earlier  period  of  life  than  the  monomaniacs,  and, 
therefore,  some  of  them  can  be  prevented,  the  brain  being  still  plastic. 


LECTURE    VII. 

STATES  OF  MENTAL  ENFEEBLEMENT  {DEMENTIA,  AMENTIA, 
PSFCHOPARESIS,  CONGENITAL  IMBECILITY,  IDIOCY). 

We  use  the  term  "mental  enfeeblement "  not  in  its  wide  and  popular 
sense,  meaning  any  mental  weakness  or  disease  whatever,  but  in  a  special 
and  scientific  sense.  It  may  be  defined  as  "a  general  weakening  of  the 
mental  power,  comprising  usually  a  lack  of  reasoning  capacity,  a  diminu- 
tion of  feeling,  a  lessened  volitional  and  inhibitory  power,  a  failure  of 
memory,  and  a  want  of  attention,  interest,  and  curiosity  in  a  person  who 
had  those  mental  qualities  and  lost  them,  or  has  come  to  the  age  to  have 
them  and  they  have  not  been  developed."  There  are  two  great  physio- 
logical periods  of  meijtal  enfeeblement,  viz.,  in  childhood  and  old  age. 
Consider  the  condition  of  a  child  of  two  as  to  reasoning  power.  There 
are  many  words  indicating  a  lack  of  mental  power  that  h^ve  two  mean- 
ings, a  pleasant  or  an  unpleasant  one,  according  as  they  are  used  in  refer- 
ence to  a  child  whose  mindlessness  is  physiological,  or  to  a  man  in  whom 
it  would  be  morbid.  What  more  charming  than  "  prattle,"  "  artlessness," 
"childishness,"  "  innocence,"  as  applied  to  a  child  ?  But,  said  of  a  man, 
they  mean  "chatter,"  "silliness,"  "want  of  sense,"  or  "unwisdom." 
If  the  brain  development  is  arrested  before  birth  or  in  childhood,  we  have 
congenital  imbecility  and  idiocy — Amentia.  Dotage  must  be  reckoned 
as  natural  at  the  end  of  life.  It  is  not  actually  the  same  as  senile  de- 
mentia, but  there  is  no  scientific  difference.  Mental  enfeeblement,  both 
in  judgment,  feeling,  memory,  and  volition,  frequently  occurs  in  and  after 
bodily  diseases,  especially  after  fevers.  It  also  always  occurs  in  the  pro- 
cess of  starvation  to  death.  It  frequently  is  seen  after  the  exhaustion 
of  long  journeys,  great  exertions,  severe  campaigns,  and  great  mental 
tension,  strains,  or  efforts,  such  as  business  crises,  sieges,  etc.  It  also 
occurs  after  sudden  or  great  emotional  shocks,  such  as  loss  of  children. 
Now,  in  all  these  cases  the  actual  psychological  condition  may  be  the 
very  same  as  in  patients  laboring  under  mental  diseases  proper,  or  tech- 
nical insanity.  Yet  we  do  not  practically  reckon  them  in  that  category, 
except  they  are  unusually  severe  or  very  lasting.  Still,  the  student  of 
brain  function  and  medical  psychology,  as  well  as  the  practical  physician, 
finds  a  study  of  all  those  conditions  of  mental  enfeeblement  most  profit- 
able. 

The  conditions  of  mental  enfeeblement  that  are  ordinarily  reckoned 
among  mental  diseases  may  exist  in  every  possible  degree,  from  the 
merest  dulling  of  the  keen  edge  of  certain  mental  faculties  up  to  com- 
plete loss  of  intelligence,  feeling,  and  memory.  One  man  may  be  just 
so  much  altered  that  his  friends  say,  "  He  is  not  the  same  man  he  once 
was,"  and  another  may  not  be  able  to  comprehend  or  answer  the  simplest 


STATES    OF    MENTAL    ENFEEBLEMENT.  205 

questions  or  to  recollect  his  own  name.  A  clever  man  may  be  left  in 
such  a  condition  that  in  his  dementia  he  is  more  intelligent  than  another 
stupid  man.  A  man  may,  while  he  is  not  energizing  mentally,  seem  as 
other  men  are,  or  as  he  once  was ;  but,  when  he  comes  to  think,  or  act, 
or  work,  it  is  seen  that  he  cannot  do  so  as  before.  In  most  cases  all  the 
mental  faculties  are  enfeebled  together,  either  pretty  equally  or  one  suf- 
fering more  and  another  less.  In  a  few  cases  some  mental  faculties  are 
left  almost  intact,  while  others  are  almost  destroyed.  I  have  a  patient 
now  whose  brain  was  once  a  most  energetic  and  subtle  one  and  his  mem- 
ory extraordinarily  retentive,  who  talks  quite  rationally  on  all  kinds  of 
subjects,  if  they  are  suggested  to  him  or  if  you  "draw  him  out,"  and 
argues  most  correctly,  but  who  never  originates  anything,  is  utterly  help- 
less in  action,  and  who  cannot  tell  you  the  day  of  the  week  or  what  he 
had  for  breakfast.  The  originating  power  of  mind,  spontaneity  of  thought 
and  feeling,  active  vigor  of  will  that  highest  quality  of  all,  are  always 
diminished  or  lost  in  dementia.  I  know  a  man  Avho  when  well  always 
impressed  those  Avith  whom  he  came  in  contact  as  being  a  leader  of  men, 
and  who  now,  after  an  attack  of  mania,  has  lost  the  power  of  producing 
that  impression.     As  one  of  his  friends  said  to  me — "I  was  always 

afraid  of  Mr. ,  and  never  could  be  familiar  with  him.     Now  that's 

gone."  Pathologically  and  psychologically,  the  mental  state  of  such  a 
man  is  the  same  in  kind,  if  not  in  degree,  as  the  absolute  dementia  of 
asylums.  Yet,  of  course,  the  degree  makes  a  great  difference  from  a 
legal  and  social  point  of  view.  A  man's  mind  may  be  slightly  weakened 
and  yet  he  may  enjoy  his  personal  freedom,  and  another  man  who  is 
more  affected  has  to  be  deprived  of  this ;  but  there  is  no  line  of  demar- 
cation, and  no  test  to  distinguish  between  technical  sanity  and  technical 
insanity  in  dementia. 

It  must  be  remembered  that  in  all  insanity  there  is  an  element — often 
a  strong  one — of  mental  enfeeblement  pure  and  simple.  Most  cases  of 
exaltation  have  enfeeblement  of  judging  power  as  well  as  of  feeling. 
Many  cases  of  melancholia  are  enfeebled  as  well  as  depressed. 

A  typical  case  of  dementia  is  one  affected  as  this  young  man  E.  A.  is. 
As  he  came  into  the  room  his  walk  was  hesitating  and  almost  shuffling, 
and  you  see  his  bodily  attitude  is  one  of  diminished  muscular  and 
nervous  vigor.  He  stoops,  his  face  is  vacant-looking,  he  has  no  curiosity 
as  to  where  he  is  coming,  or  as  to  what  I  am  saying  about  him ;  when  I 
ask  him  his  name  he  tells  it,  but  cannot  tell  the  day,  or  month,  or  year. 
In  asking  him  questions,  I  have  to  adopt  means  by  speaking  loud  and 
sharply,  or  by  patting  his  arm,  to  rouse  his  attention  to  listen  to  me. 
His  mental  operations  are  slow  as  well  as  weak,  for  it  takes  his  brain 
long  apparently  to  take  up  impressions  from  the  senses,  and  still  longer 
to  evolve  the  outward  process  of  speech  in  response.  When  I  ask  him 
"where  were  you  born  ?"  he  says,  after  a  minute,  "  Oh  yes,  I  think  so." 
When  I  ask  him  "who  is  that?"  pointing  to  a  student,  "that's  my  uncle 
John."  "What  place  is  this  you  are  living  in?"  "I  don't  know." 
"Did  you  ever  ask  any  one  what  place  it  was?"  "Yes."  "Are  you 
sure?"  "No."  " How  long  have  you  been  here ? "  "This  morning." 
(He  has  been  here  six  years.)  He  cannot  reason,  he  has  almost  no  affec- 
tions, caring  for  no  one,  showing  no  pleasure  in  seeing  his  relations.     He 


206  STATES    OF    ME2fTAL    ENFEEBLEMENT. 

has  no  wishes,  hopes,  fears,  or  memory.  He  does  not  resist  anything, 
and  has  no  choice  as  between  any  two  things.  He  has  no  fineness  of 
feeling,  no  "tastes."  His  habits  would  become  dirty  and  degraded  if  not 
looked  after.  Looked  at  from  the  purely  bodily  point  of  view,  he  has 
no  keen  appetite  at  all  even  for  food,  for  he  has  been  several  times  for- 
gotten in  the  garden  over  meal-times,  and  hunger  did  not  bring  him  to 
dinner.  He  has  no  proper  sexual  appetite,  though  he  masturbates  in  an 
automatic  way.  His  temperature  is  about  a  degree  and  a  half  below  the 
normal,  his  circulation  poor,  his  hands  blue  and  cold  in  chilly  weather, 
his  muscles  flabby,  his  common  sensibility  much  diminished,  for  you  see 
pricking  Avith  a  pin  does  not  rouse  him  much.  His  digestion  and  the 
action  of  the  bowels  are  good  and  regular,  and  the  sleep  power  of  his 
brain  is  perfect,  in  fact  he  would  sleep  too  long  if  allowed  to.  There  is 
a  good  deal  of  flabby  fat  on  his  body.  Sores  are  slow  in  healing,  and 
when  he  catches  cold  he  scarcely  ever  coughs,  though  there  may  be  much 
bronchial  irritation.  The  reflex  action  of  the  cord  is  diminished,  though 
the  tendon  reflex  is  normal.  Last  of  all,  and  most  important,  that  power 
of  action  and  power  of  coordination  of  those  marvellously  innervated 
strands  of  muscles  in  the  face  that  give  "expression"  to  the  face,  seem 
to  be  utterly  dulled  and  diminished,  and  the  eyes  are  expressionless.  It 
is  clear  that  all  the  higher  qualities  of  his  brain  are  gone,  and  that  even 
the  lower  qualities  are  much  enfeebled.  He  is  now  demented ;  but  he 
was  once  an  intelligent,  educated  man,  who  had  an  attack  of  acute  mania, 
and  was  left,  after  that  had  passed  away,  as  you  see  him. 
There  are  five  chief  kinds  of  dementia : 

1.  Secondary  {Ordinary  or  Sequential)  Dementia^  following  mania 
and  melancholia  or  other  insanity. 

2.  Primary  Enfeehlement  {Congenital  Tmbeeility,  Idiocy,  Amentia, 
Cretinism),  the  result  of  deficient  brain  development,  or  of  brain  disease 
in  early  life. 

3.  Senile  Dementia. 

4.  Organic  Dementia,  the  result  of  gross  organic  brain  disease. 

5.  Alcoholic  Dementia,  following  the  long-continued  excessive  use  of 
alcohol.  As  the  last  three  varieties  will  be  described  under  the  headings 
of  the  senile,  paralytic,  and  alcoholic  insanities,  I  shall  not  further  refer 
to  them  here. 

As  every  variety  of  dementia  is  incurable,  and  as  the  medical  profession 
outside  of  public  institutions  has  little  to  do  with  its  treatment  or  manage- 
ment, I  shall  devote  little  time  to  this  variety  of  mental  disease. 

Secondary  Dementia. — This  always  follows  and  is  in  a  way  the  result 
of  more  acute  mental  disease,  such  as  mania  and  melancholia,  and  there- 
fore may  be  called  sequential.  It  is  the  most  characteristic,  the  most 
common,  and  the  most  important  of  all  the  kinds  of  mental  enfeehlement, 
so  that  when  you  hear  of  a  person  laboring  under  dementia,  it  is  usually 
this  that  is  meant.  It  is  dementia  par  excellence,  therefore.  It  is  the 
goal  of  all  chronic  insanities. 

When  a  condition  of  morbid  mental  exaltation,  especially  when  this 
has  been  acute  mania,  has  existed  for  a  long  time,  we  find  that  the  over- 
action  usually  causes  a  tendency  to  mental  weakness  as  the  exaltation 
passes  away,  and  that  this  is  apt  to  be  left  as  a  permanent  brain  condi- 


STATES    OF    MENTAL    ENFEEBLEMENT.  207 

tion.  This  is  dementia.  The  same  tendency  is  seen,  but  to  a  less  degree, 
as  the  result  of  a  prolonged  condition  of  mental  depression.  This  is  the 
termination  ■we  most  of  all  dread  in  acute  insanity.  All  mental  diseases 
when  long  continued  tend  towards  dementia.  When  the  matter  is  looked 
at  pathogenetically  it  might  be  thus  stated.  For  the  production  of  most 
'cases  of  mental  disease  we  need  a  morbid  neurotic  heredity,  or  a  prolonged 
cause  of  irritation  or  exhaustion.  Then  comes  an  exciting  cause  of  dis- 
turbance strong  enough  to  convert  this  tendency,  this  potentiality,  into 
an  actual  disease,  and  a  severe  outburst  of  abnormal  action  occurs  in  the 
brain  convolutions.  The  symptoms  of  this  are  the  maniacal  exaltation, 
or  the  melancholic  depression.  The  abnormal  action  means  abnormal 
nutrition  as  well  as  abnormal  energizing.  This,  like  all  long-continued 
abnormal  nutrition,  tends  injuriously  to  affect  the  minute  and  delicate 
neurine  structure,  the  capillaries,  the  lymphatics,  and  the  packing  tissue 
of  the  gray  matter  of  the  convolutions.  It  even  affects,  as  we  have  seen, 
the  structure  of  the  surroundings  of  the  brain,  the  pia  mater,  the  large 
vessels,  the  arachnoid,  the  cerebro-spinal  fluid,  the  dura  mater,  and  the 
calvarium.  When  this  storm  of  morbid  action  at  last  passes  off  or  ex- 
hausts itself,  the  cells  have  become  so  damaged  that  they  are  no  longer 
fit  to  become  the  vehicles  of  normal  mentalization — their  nutrition,  their 
storage  of  energy,  their  receptive  and  their  productive  poAver  being  im- 
paired. The  mental  result  of  this  is  enfeeblement  or  dementia.  Some- 
what the  same  thing  occurs  in  coarser  forms  in  all  the  coarser  tissues  and 
organs,  e.  g.,  the  permanent  damage  to  locomotion  that  results  from  long- 
continued  rheumatic  inflammation  of  a  joint,  to  digestion  from  prolonged 
over-stimulation  of  the  stomach,  to  sight  from  the  intense  lights  of  the 
desert  or  the  Alps,  to  hearing  from  the  continuous  clang  of  an  iron  ship- 
building yard.  You  will  remember,  however,  that  from  the  very  begin- 
ning there  was  probably  a  tendency  towards  that  weakening  of  the  mental 
functions  of  the  brain  which  we  call  dementia.  The  great  difference  in 
effect  between  partial  loss  of  function  in  the  brain  convolutions,  and  in 
any  other  organ  of  the  body,  is  that  in  the  former  case  the  man  dies  to 
all  intents  and  purposes,  socially  his  right  to  liberty  is  gone,  and  his  place 
among  his  fellow-men  is  taken  by  another. 

The  following  is  a  typical  case  of  secondary  dementia.  E.  B.,  a  hand- 
some, well-developed,  intelligent,  and  well-educated  young  woman,  whose 
mother  was  insane,  her  sister  a  woman  that  "no  one  could  live  with," 
and  a  brother  a  confirmed  drunkard,  had,  at  the  age  of  twenty-four,  a 
cross  in  a  love  affair.  At  first  she  was  depressed  in  spirits  for  a  few 
months,  then  she  took  to  a  morbid  eccentric  religionism,  and  in  six 
months  became  acutely  maniacal.  She  remained  so  for  a  year.  At  the 
end  of  that  time  her  whole  appearance  and  expression  of  face  were  so 
different  from  the  attractive  girl  she  had  been  that  her  friends  scarcely 
recognized  the  same  person.  Her  face,  that  "mirror  of  the  soul,"  ex- 
pressed no  doubt  the  fancies  and  the  passions  that  were  evolved  in  her 
morbid  brain,  but  there  was  also  a  vacancy  and  a  physiological  degrada- 
tion very  manifest.  About  that  time  she  began  to  sleep  better,  then  to 
eat  better,  then  to  talk  and  scream  less,  then  to  be  able  to  sit  still  longer 
and  control  herself  more.  This  process  of  gradual  quiescence  went  on 
for  six  months,  ^ith  occasional  spurts  of  exaltation,  and  short  relapses 


208  STATES    OF    MENTAL    ENFEEBLEMENT. 

into  active  mania.  By  that  time  she  was  getting  fat,  sluggish,  devoid  of 
interest  in  anything,  and  with  no  emotion.  She  did  not  ask  for  those 
who  had  been  dearest  to  her,  or  exhibit  any  pleasure  when  they  came  to 
see  her.  She  often  laughed  and  talked  to  herself  Her  speech  and  con- 
duct were  best  described  as  very  "  silly."  Her  memory  seemed  gone. 
All  that  education  had  done  for  her  brain  seemed  to  have  disappeared,  or 
could  only  be  brought  out  in  disjointed,  incoherent  scnips.  The  nameless 
charms  of  dress  and  manner  and  behavior  of  a  bright  young  lady  had  ab- 
solutely disappeared.  She  was  slovenly  and  not  over  cleanly,  showed 
few  likes  and  dislikes,  no  will  of  her  own.  Her  face  was  vacant,  her 
eyes  expressionless,  her  motions  slow  and  wanting  in  purpose  and  vigor, 
and  her  nutrition  flabby.  But  she  slept  well,  she  ate  very  well  but 
with  little  choice  of  foods,  her  digestion  was  good,  her  bowels  regular, 
and  her  menstruation,  which  had  ceased  during  the  whole  of  the  maniacal 
period,  became  regular.  She  is  in  fact  dead  to  mental  life  in  any  proper 
sense,  and  so  has  remained  now  for  many  yeai-s,  and  so  will  remain  till 
she  dies  of  some  disease  that  will  not  necessarily  be  a  brain  disease  at  all. 
Her  chances  of  life  are  probably  below  those  of  a  sound  person  at  her 
age,  but  she  may  live  long.  These  are  the  cases  that  form  the  bulk  of 
the  old  inmates  of  asylums,  and  about  whom  their  friends  say,  they  seem 
to  outlive  all  their  sane  relations  and  friends,  because  they  are  free  from 
the  worries  and  cares  of  life,  and  live  a  regulated  existence  under  medical 
rule. 

In  certain  things  E.  B.  did  improve  after  the  first  two  years.  Her 
brain  was  subjected  to  a  reeducation  of  a  simple  kind,  but  its  capacity 
for  this  was  limited.  It  had  no  power  of  acquiring  any  sort  of  high 
attainment  in  anything.  She  was  taught  to  dress  herself  more  neatly, 
to  do  a  little  simple  work,  to  observe  certain  hours  for  meals,  etc.  Curi- 
ously enough  certain  mechanical  achievements  in  which  she  had  been 
well  educated,  so  that  they  had  become  the  automatic  property  of  the 
ideo-motor  brain  centres,  came  back  to  her  easily,  and  were  well  done. 
Such  were  certain  kinds  of  ladies'  work,  and  sewing.  It  was  found  she 
could  play  some  of  her  old  tunes  on  the  piano,  but  the  music  was  me- 
chanical. All  the  life  and  soul  were  out  of  it.  She  could  not  be  taught 
the  simplest  of  new  tunes,  no  new  stitching,  no  new  dance  steps.  Every 
now  and  again  she  had  a  slight  return  of  the  maniacal  exaltation,  begin- 
ning usually  at  a  menstrual  period,  and  at  the  very  beginning  of  one  of 
these  she  would  look  and  act  more  like  her  sane  self  than  at  any  other 
time.  She  is  placed  under  the  control  of  social  inferiors,  and  she  does 
not  resist.  She  lives  in  the  asylum,  and  she  does  not  ask  why.  She 
has  no  money,  and  she  does  not  seek  it.  She  forms  no  attachment,  and 
she  associates  with  the  most  incongruous  people  without  feeling  it. 

This  is  the  type  of  all  the  cases  of  secondary  dementia  in  its  causes 
and  symptoms.  But  there  are,  of  course,  great  variety  in  the  details  of 
the  clinical  pictures.  Attacks  of  melancholia  may  be  followed  by  de- 
mentia, but  this  is  not  nearly  so  common  as  in  the  case  of  mania,  except 
in  the  senile  cases.  Nothing  more  conclusively  shows  that  conditions  of 
depression  are  essentially  less  profound  departures  from  mental  health 
than  conditions  of  exaltation,  than  the  lesser  tendency  to  dementia  after 
the  former.     When  it  does  occur  it  is  a  less  complete  dementia  than 


STATES    OF    MENTAL    ENFEEBLEMENT.  209 

occurs  after  mania,  and  is  nearly  always  tinged  with  a  melancliolic  cast. 
Out  of  one  hundred  cases  of  dementia  taken  at  random,  whose  histories 
I  know,  only  twenty  followed  melancholia.  All  sorts  of  partial  dementia 
occur.  I  have  many  patients  in  the  asylum  who  look  like  other  people, 
who  converse  with  you  rationally  when  you  talk  Avith  them,  and  have  no 
delusion,  but  they  have  no  initiative,  no  originating  power,  no  active 
desires,  no  power  of  self-guidance,  or  resistive  capacity.  I  sent  such  a 
man  out  of  the  asylum  lately,  and  he  just  sat  down  at  home,  would  not 
work,  would  scarcely  get  out  of  bed,  cared  nothing  for  cleanliness  and 
the  decencies  of  life,  and  only  earned  ten  shillings  the  six  months  he  was 
out.  Some  persons  in  this  state  do  some  work  in  the  world  outside 
under  suitable,  interested,  and  kindly  guidance.  Sometimes  a  man  is 
left  after  a  maniacal  attack  mentally  twisted,  or  has  a  curious  mixture  of 
enfeeblement  and  obstinacy.  I  know  a  gentleman  who  once  had  an 
attack  of  mania,  and  who  now  shows  a  mild  dementia  chiefly  in  either 
defying  or  being  unconscious  of  the  conventionalities  of  life.  He  goes 
about  the  streets  often  in  a  dressing-gown  and  slippers,  he  pays  no  defer- 
ence whatever  to  ladies,  he  eats  at  irregular  hours,  is  "  never  to  be  de- 
pended upon  "  in  anything,  and  yet  he  manages  his  affairs  and  seems 
happy  in  a  way.  In  some  cases  a  man  shows  mild  dementia  by  slight 
degradations  in  his  habits  and  feelings.  I  know  such  a  man  who  is 
simply  not  so  sensitive  as  he  once  was,  not  so  particular  in  small  things, 
is  content  with  worse  fitting  clothes,  and  is  not  so  neat  and  clean  in  his 
ways.  I  know  another  case  where  it  shows  itself  by  what  his  friends  call 
excessive  laziness.  He  will  not  walk  or  work,  or  do  anything  in  fact, 
but  sit  in  the  house  and  smoke.  I  know  many  cases  where  it  shows 
itself  in  deficient  inhibitory  power  over  the  appetites,  the  patients  taking 
to  drinking  and  sexual  immorality.  In  other  cases  they  simply  sink 
into  a  lower  social  stratum,  and  evidently  are  more  happy  there  than  in 
their  own.  Such  cases  are  commonly  reckoned  as  being  examples  of 
mere  eccentricity,  but  they  are  scientifically  cases  of  partial  and  limited 
enfeeblement  of  mind. 

There  are  certain  things  that  are  of  the  greatest  importance  in  relation 
to  secondary  dementia.  The  first  of  these  is  undoubtedly  the  length  of 
the  attack  of  the  acute  primary  insanity.  The  risk  of  dementia  is  in 
direct  ratio  to  the  length  of  the  maniacal  exaltation.  This  does  not 
quite  apply  to  melancholic  depression,  the  existence  of  which  for  long 
periods  is  not  so  damaging  to  convolution  function.  Beyond  a  doubt 
there  are  some  cases  that  become  demented  after  only  a  few  weeks  of 
maniacal  excitement,  when,  in  fact,  it  is  clear  that  the  tendency  to  it  was 
present  from  the  beginning,  and  when  it  was  an  inevitable  doom  of  their 
brains.  These  are  the  brains  which  seem  to  have  innate  energizing 
power  in  them  to  last  only  for  so  many  years,  and  then  they  fail  and  die 
as  to  their  higher  mental  functions.  Of  course,  it  may  be  asked — How 
do  we  know  that  this  is  not  the  case  in  all  those  that  become  demented, 
without  reference  to  the  preceding  mania  at  all  ?  May  not  the  mania 
simply  be  one  incident  on  the  road  to  mindlessness,  and  not  the  cause  of 
the  latter  at  all  ?  It  is  right  to  ask  such  questions.  On  the  whole,  the 
facts  of  a  great  number  of  cases  make  one  conclude  that  a  maniacal 

14 


210  STATES    OF    MENTAL    ENFEEBLEM  ENT, 

attack  does  damage  the  brain  convolutions,  and  that  the  longer  it  lasts 
the  more  likely  is  that  damage  to  be  permanent. 

2.  The  character  of  the  primary  attack  influences  the  tendency  to 
dementia  as  well  as  its  duration.  The  more  acute  the  attack,  the  greater 
tendency  there  is  to  subsequent  mental  enfeeblement.  The  acutely 
delirious  state  is  the  most  damaging  of  all,  no  doubt.  But  to  this  rule 
there  are  many  exceptions.  I  have  now  a  case  quite  demented  where  the 
primary  maniacal  attack  was  very  mild — only  amounting  to  simple 
mania,  and  that  lasting  but  for  a  month  or  so.  Then  enfeeblement 
showed  itself,  and  slowly  progressed,  till  in  four  years  there  was  deep 
dementia.  I  have  even  seen  a  few  cases  where  a  mental  enfeeblement 
began  ah  initio  without  mania,  without  melancholia,  without  gross  organic 
disease  or  epilepsy  or  alcoholism.  Such  cases  are  very  rare  indeed,  how- 
ever. We  can  usually  get  evidence  of  some  symptoms  of  mania  or 
melancholia  if  we  have  the  means  of  ascertaining  correctly  the  patient's 
state.  The  habit  of  masturbation  may  cause  dementia  as  a  primary 
mental  disease  in  young  people  with  a  strong  neurotic  heredity,  without 
preliminary  mania.  But  the  great  difference  in  the  onset  of  the  secondary 
or  ordinary  dementia  from  that  of  the  organic  dementia  is  the  existence 
of  a  preceding  attack  of  mania  or  melancholia  in  the  former  and  its 
absence  in  the  latter. 

3.  The  number  of  previous  attacks  is  no  doubt  of  the  utmost  impor- 
tance in  the  causation  of  dementia,  except  in  the  case  of  those  typical 
examples  of  alternating  insanity  called  folie  circulairc,  which  I  have 
described.  The  case  of  D.  B.  (p.  175),  whose  brain  has  had  over  two 
hundred  attacks  of  acute  maniacal  excitement  in  the  last  thirty-six  years, 
and  yet  is  not  wholly  demented,  is  a  most  striking  example  of  the 
recuperative  power  of  the  brain  convolutions.  Speaking  generally,  the 
tendency  to  dementia  increases  in  each  successive  attack.  The  relapsing 
tendency  of  adolescent  insanity  is  to  my  mind  an  illustration  of  the  two 
inherent  tendencies  in  such  brains — the  one  to  mental  recovery  and  life, 
the  other  to  mental  death.  And  we  notice  that  the  sooner  the  relapsing 
tendency  stops,  the  more  likely  is  the  former  result  to  occur.  It  often 
happens  that  after  a  first  attack  of  insanity  certain  mental  peculiarities 
are  left,  seen  it  may  be  only  by  the  patient's  near  relations  and  intimate 
friends.  He  is  not  "  quite  the  same  man."  Each  succeeding  attack  that 
he  has  leaves  him  with  more  marked  peculiarities  or  weaknesses,  until  the 
final  irreparable  break-down  of  dementia  is  reached.  You  will  constantly 
be  asked  your  opinion  of  a  man  who  has  once  been  insane,  to  hold 
appointments,  to  accept  trusts,  to  contract  marriage,  etc.  One  must 
frequently  give  a  guarded  answer,  and  this,  not  only  after  examination 
yourself,  but  after  most  minute  inquiry  from  disinterested  friends  who 
have  seen  most  of  him.  I  find  it  often  more  difficult  to  pronounce  a  man 
sane  and  mentally  competent  than  to  pronounce  him  insane.  There  is  no 
doubt  that  a  man  may  fiilly  and  perfectly  recover  from  attacks  of  insanity. 
They  may  leave  not  a  trace  behind  them  in  any  shape  or  form.  I  could 
point  to  hundreds  of  men  and  women  who  have  been  insane,  and 
who  now  do  their  work  as  well  as  ever  they  did.  It  is  a  grave  injustice 
to  regard  all  men  who  have  been  insane  as  tainted  and  unfit  to  hold 
appointments  of  trust,  though  this  is  unfortunately  a  common  prejudice. 


STATES    OF     MENTAL    ENFEEBLEMENT .  211 

There  is  a  risk,  no  doubt,  but  it  would  be,  indeed,  a  terrible  thing  if 
mental  disease  were  regarded  as  necessarily  implying  an  incurable  mental 
deficiency  or  a  relapse  some  day. 

4.  The  fourth  element  that  aifects  the  occurrence  of  dementia,  and 
that  we  have  to  take  into  account,  is  the  heredity  of  the  patient.  The 
common  opinion  undoubtedly  is,  both  among  the  profession  and  general 
public,  that  a  strong  family  predisposition  to  insanity  means  a  bad  chance 
of  recovery  in  any  particular  attack,  in  other  words,  a  tendency  to 
dementia.  Now  this  is  not  true  as  a  matter  of  fact.  Strongly  hereditary 
cases  are  the  most  curable  of  all,  but  they  are  most  liable  to  recur ; 
though  many  of  them  are  undoubtedly  incurable  from  the  beginning.  A 
strong  and  direct  heredity  implies  three  things,  (1)  instability  of  brain, 
(2)  liability  to  attacks  at  early  ages,  and  (3)  liability  to  a  recurrence 
after  cure. 

5.  The  fifth  element  in  our  prognosis  is  the  age  of  the  patient.  A  man 
who  has  youth  on  his  side  has  a  much  better  chance  of  coming  out  of  a 
brain  storm  of  acute  mania  unharmed ;  but  to  disturb  this  calculation 
come  in  those  cases  of  mental  diseases,  occurring  at  early  ages,  and  in 
brains  whose  whole  stock  of  mental  protoplasm  is  exhausted  in  a  few 
years  instead  of  being  sufficient  to  last  through  the  whole  life  of  the 
body.  As  we  shall  see  when  I  come  to  speak  of  senile  insanity,  we  may 
have  attacks  of  mania  and  melancholia  in  the  advanced  periods  of  life, 
when  the  brain  is  in  the  stage  of  decadence  and  the  arteries  are  very 
diseased,  recovered  from  altogether,  or  only  leaving  a  mild  senility. 

6.  There  is  a  state  of  mental  weakness  that  frequently  follows  sharp 
attacks  of  mania  and  melancholia,  which  closely  resembles  dementia,  and 
yet  is  quite  curable.  It  is  in  reality  a  mild  form  of  stupor,  and  I  shall 
treat  it  under  that  heading.  It  is  analogous  to  the  stage  of  temporary 
exhaustion  and  reaction  that  follows  all  acute  diseases.  It  is  the  period 
of  functional  rest  but  trophic  activity,  during  which,  through  the  vis 
medicatrix  naturce,  organs  that  have  been  diseased  heal,  tissues  whose 
nutrition  has  been  disturbed  eliminate  morbid  elements  and  become 
normal,  and  functions  that  have  been  altered  or  suspended  resume  slowly 
their  activity.  This  period  is  of  the  highest  importance  for  treatment. 
Rest,  nutritives,  tonics,  sometimes  stimulants,  and  counter-irritants  are 
then  indicated.  It  is  the  time  for  the  use  of  the  stimulating  nerve  tonics 
and  vaso-motor  stimulants,  such  as  strychnine,  quinine,  phosphorus,  the 
phosphates  and  hypophosphites,  shower-baths,  friction  to  skin,  the  inter- 
rupted and  continued  currents,  Turkish  baths,  followed  by  brisk  sham- 
pooing, and  blisters  to  the  back  of  the  head.  I  have  a  man  who  had 
become  dull,  stupid,  and  lethargic  after  an  attack  of  acute  mania,  and  he 
*' wakened  up"  visibly  under  such  treatment.  I  had  a  young  woman 
who  had  ceased  to  speak,  rouse  up  and  begin  talking  and  working  imme- 
diately after  a  blister  had  been  applied  to  the  back  of  her  bead.  I  had  a 
man  who  roused  up  not  only  in  mind  but  in  muscular  activity,  and  in  vaso- 
motor force,  his  hands  getting  warm  instead  of  blue,  under  the  use  ot 
Parrish's  syrup  of  the  phosphates.  This  was  stopped  in  a  fortnight  and 
he  at  once  fell  back.  It  was  renewed  and  he  picked  up,  and  again 
stopped  and  he  fell  back.  It  was  given  continuously  for  three  months 
till  he  recovered  completely. 


212  states  of  mental  enfeeblement. 

Primary  Enfeeblement  (Idiocy,  Congenital  Imbecility,  Amen- 
tia).— I  do  not  propose  to  say  much  about  the  conditions  of  primary 
mental  enfeeblement,  but  rather  to  glance  at  a  few  of  the  most  typical 
varieties.  Ireland's^  definition  is  that  "  idiocy  is  a  mental  deficiency  or 
extreme  stupidity,  depending  upon  malnutrition  or  disease  of  the  nervous 
centres,  occurring  either  before  birth  or  before  the  evolution  of  the  mental 
faculties  in  childhood."  "  Imbecility  is  generally  used  to  denote  a  less 
decided  degree  of  mental  incapacity."  In  short,  idiocy  and  imbecility 
are  conditions  of  mental  enfeeblement  resulting  from  want  of  brain 
development  before  birth  or  in  childhood.  The  mental  faculties  were 
never  there,  their  organ  being  unfit  to  manifest  them.  In  dementia,  as 
we  have  seen,  they  were  destroyed  or  enfeebled  in  a  previously  normal 
brain.  It  is  necessary  that  medical  men  in  practice  should  have  a  general 
knoAvledge  in  regard  to  this  as  to  any  other  disease  about  which  their 
opinion  may  be  asked.  It  is  well  to  bear  in  mind  certain  things  in  regard 
to  idiocy.  1.  That  there  are  great  varieties  of  the  condition,  both  as  to 
symptoms,  causes,  treatment,  eduoability,  and  prognosis.  2.  That  the 
mental  deficiency  is  always  accompanied  by  bodily  weakness  of  some  sort, 
trophic,  resistive,  and  motor,  which  can  often  be  treated  with  good  effect 
by  the  ordinary  resources  of  our  profession.  3.  That  by  heredity  and 
physiological  connection  it  is  apt  to  be  associated  with  scrofula,  tubercu- 
losis, drunkenness,  insanity,  and  crime.  4.  That  the  main  instrument  of 
treatment  must  be  a  general  bodily  and  mental  education  of  a  special 
kind,  adapted  to  the  physiological  educability  and  potentialities  of  the 
individual  brain  under  treatment. 

Congenital  Imbecility. — This  may  exist  in  every  degree,  from  the 
smallest  amount  of  mental  weakness  down  to  idiocy.     Here  is  a  case : 

E.  C,  now  twenty-five,  of  a  family  in  which  both  drunkenness  and 
insanity  had  occurred.  When  a  child  he  was  well  developed,  and 
apparently  like  other  children,  till  he  was  about  three  or  four  years  of 
age,  when  it  was  noticed  that  he  was  not  so  bright,  not  so  imitative,  and 
not  so  observant  as  a  child  at  that  age  should  be.  Speech  was  long  in 
coming  and  difiicult  to  learn.  As  he  grew  older  he  could  learn  almost 
nothing  at  school ;  his  school-fellows  annoyed  him,  and  he  showed 
violent,  ungovernable  passion  and  violence.  The  faculty  of  inhibition  is 
almost  always  weak  in  imbeciles,  but  they  are  not  all  passionate  or  ungov- 
ernable. At  puberty  he  got  much  more  difficult  to  manage  at  home,  and 
all  his  weaknesses  and  peculiarities  were  thus  more  observable.  Unfortu- 
nately he  was  not  then  sent  to  a  special  institution  for  the  training  of 
imbeciles.  He  could  have  been  then  taught  much  more  than  he  now  knows. 
In  fact,  I  see  no  reason  why  he  should  not  have  learned  some  trade 
or  mechanical  work,  and  done  it  in  a  moderately  efficient  way.  He  got 
so  irritable,  and,  when  in  a  passion,  so  violent,  that  he  had  to  be  sent 
here  about  ten  years  ago.  He  has  settled  down  into  the  life  and  routine 
of  the  place,  is  cleanly,  tidy,  and  orderly  in  his  habits,  industrious 
in  simple  matters,  such  as  bed-making,  floor-washing,  but  is  still  very 
passionate  and  impulsive.  He  is  happy  and  contented,  and  has  no 
unftilfilled  ambitions  or  longings  to  satisfy.     Look  at  him.     He  is  fairly 

^  Idiocy  and  Imbecility,  by  W.  W.  Ireland,  M.D. 


STATES    OF     MENTAL    EN  FEEBLEMENT.  213 

developed.  At  ten  yards'  distance  you  would  say  he  was  an  ordinary- 
looking  young  man.  When  you  observe  him  closely  you  see  there  is  a 
weakness  in  his  expression  of  face,  a  lack  of  mind  in  his  eye,  and  a  sort 
of  shuffle  in  his  walk,  while  all  his  movements  lack  purpose  and  concise- 
ness. When  he  smiles  he  looks  silly,  and  his  speech  is  rather  defective. 
You  see  at  once  there  is  no  force  in  him  of  any  sort,  motor  or  mental. 
When  further  tested,  his  memory  is  seen  to  be  defective,  he  cannot  tell 
you  how  much  four  added  to  four  and  two  off  is.  He  can  write,  but  like 
a  schoolboy.  You  see  that  he  is  unfit  to  guide  himself,  to  manage  his 
affairs,  to  earn  unaided  his  livelihood,  or  to  resist  any  sort  of  temptation 
put  in  his  way.  He  is  in  good  bodily  health,  eats  and  sleeps  well,  enjoys 
simple  pleasures  like  dancing,  concerts,  and  juggler's  entertainments,  and 
may  live  long. 

E.  C.  is  a  good  type  of  the  must  common  form  of  congenital  imbecile. 
There  are  others  where  one  has  much  more  difficulty  in  determining 
whether  they  shall  enjoy  civil  rights  and  liberty,  be  allowed  to  marry, 
etc.,  being  very  near  the  minimum  legally  sane  line.  Such  persons 
become  the  dupes  of  designing  people,  cannot  resist  temptation,  or  control 
natural  desires,  and  often  become  the  worst  kind  of  dipsomaniacs.  Some 
imbeciles  show  special  talent  in  certain  directions,  some  in  music,  some  in 
drawing,  some  in  imitation,  some  in  a  kind  of  constructiveness ;  some,  who 
are  of  a  criminal  class,  are  bad  and  depraved  from  the  beginning — are 
born  imbecile  criminals.  As  to  treatment,  the  great  things  are,  carefully 
to  develop  the  body,  to  keep  it  always  fat,  not  to  give  much  animal  food 
or  stimulating  diet,  especially  at  puberty,  to  train  in  good  habits — bodily, 
mental,  and  moral — to  make  their  lives  systematic  and  orderly,  to  avoid 
occasions  of  ill-temper,  to  punish  justly  and  usually  by  deprivation  of 
indulgences,  to  send  to  institutions  for  training  and  not  to  ordinary 
lunatic  asylums  till  this  is  unavoidable. 

Congenital  imbeciles  may  have  attacks  of  maniacal  excitement  or 
melancholic  depression — in  fact,  are  subject  to  them.  They  may  become 
dangerous  and  even  homicidal ;  they  may,  after  an  attack,  have  secondary 
stupor,  or  may  become  demented  as  compared  with  their  primitive  condi- 
tion.    They  are  often  terrible  masturbators. 

Idiocy. — I  find  the  most  useful  classification  of  idiocy  is  that  of  Dr. 
Ireland,  as  follows :  1.  Genetous ;  2.  Eclampsic ;  3.  Epileptic ;  4. 
Paralytic  ;  5.  Inflammatory  ;  6.  Traumatic  ;  7.  Microcephalic  ;  8.  Hydro- 
cephalic ;  9.  By  deprivation  of  the  senses ;  and  10.  Cretinism. 

Genetous  idiocy  is  that  variety  which  begins  before  birth.  E.  D.  is  a 
very  unfavorable  case.  She  is  now  twenty-four,  and  never  showed  any 
mental  potentiality  at  all  from  the  beginning.  She  showed  no  affection, 
no  clinging  to  anyone  in  particular,  not  even  like  that  of  a  dog  to  those 
who  fed  her  and  were  kind  to  her.  She  has  never  had  any  understanding 
of  anything,  never  could  speak,  always  grunted  in  that  animal-like  way 
you  hear,  never  showed  curiosity,  imitativeness,  or  power  of  attention. 
You  see  her  body  is  squat  and  ugly,  her  temperature  low,  her  palate 
acutely  arched,  and  her  teeth  irregular  and  few  in  number.  She  has 
from  childhood  beaten  her  head  with  her  hands,  as  you  see  her  now  doing, 
just  as  the  gorillas  beat  their  breasts  in  the  African  woods.  Her  face  is 
utterly  unhuman,  hence  such  cases  have  been  called  theroid  or  beast-like. 


214  STATES    OF    MEXTAL    ENFEEBLEMENT. 

The  evolutionists  would  find  many  proofs  of  reversion  to  conditions 
common  in  the  lower  animals  in  her.  When  you  place  a  tumbler  of 
water  on  the  floor  before  her,  you  see  she  kneels  down  and  laps  it  with 
her  tongue.  She  has  not  a  rudimentary  sense  of  decency  or  sexual 
feeling.  Such  a  case  is  beyond  the  reach  of  teaching  or  training  of  any 
sort.     Nothing  can  be  done  but  to  feed  and  clothe  her  and  keep  her  clean. 

The  next  case  of  E.  E.,  is  a  much  more  hopeful  subject.  He,  too,  is 
a  genetous  idiot,  and  is  small,  ill-developed,  rather  deformed,  bandy- 
legged, cold,  feeble  in  muscle  and  trophic  power,  but  he  in  a  way 
understands  some  things  you  say  to  him,  is  always  smiling,  is  gentle,  has 
been  taught  to  be  cleanly  and  almost  tidy.  He  has  no  sexual  feelings, 
cannot  read  or  write  or  count,  and  will  probably  die  of  consumption. 

The  genetous  form  the  largest  class  of  idiots,  vary  greatly  in  the 
mental  capacity  present,  and  many  of  them  can  be  trained  in  training 
schools,  and  made  more  human  and  comfortable. 

The  eclampsic  idiots  are  those  whose  brains  have  been  injured,  and 
their  development  afterwards  retarded  by  convulsions  at  dentition.  They 
are  an  unfavorable  class  as  regards  training.  The  damage  done  to  the 
brain  and  its  envelopes  is  usually  demonstrable  after  death. 

I  produce  before  you  a  whole  series  of  epileptic  idiots.  Their  charac- 
teristics are :  1.  That  they  vary  in  mental  condition  very  much  according 
to  whether  they  are  taking  fits  or  not  at  the  time.  2.  That  the  eflfect  of 
the  constant  recurrences  of  the  epileptic  seizures  is  such  on  the  brain  that 
it  tends  to  lose  the  effects  of  training  and  to  deteriorate. 

Take  this  example  of  E  F.,  now  sixteen,  who  has  taken  fits  since  he 
was  a  year  old.  At  times  he  is  gentle  and  teachable,  and  works  in  the 
garden,  and  enjoys  life  ;  then  he  will  have  a  few  epileptic  fits,  and  he  will 
be  stupid,  dirty  in  his  habits,  and  will  forget  all  his  training.  After  that 
he  will  be  for  a  day  or  two  irritable,  violent,  impulsive,  and  even  danger- 
ous. He  articulates  in  a  childish  way.  He  is  getting  worse,  and  will,  no 
doubt,  die  some  day  in  a  fit  or  after  a  series  of  fits.  I  have  seen  the 
steady  use  of  the  bromide  of  potassium  very  usefiil  in  such  cases,  lessening 
the  number  of  the  fits  and  their  severity,  diminishing  the  irritability,  and 
improving  the  nutrition.  We  have  one  boy  here  who  is  quite  another 
being  for  the  past  four  year  under  twenty  grain  doses  three  times  a  day. 

The  paralytic  form  of  idiocy  is  represented  by  this  case  of  E.  G.,  who 
was  normal  in  body  and  mind  till  he  was  four  years  of  age.  He  then 
had  an  apoplectic  attack,  and  his  left  hand,  arm,  leg,  and  left  side  of  his 
face  and  head  are  partially  paralyzed,  ill-developed,  and  the  limbs 
shrunken,  flaccid,  and  useless  ever  since.  He  takes  sporadic  epileptic 
attacks.  He  tries  to  articulate,  but  you  cannot  make  out  what  he  says  ; 
he  is  restless,  irritable,  not  very  educable,  weak,  and  cold.  Such  cases, 
looked  at  from  the  motor  point  of  view  by  the  general  physicians,  are 
called  cases  of  Essential  paralysis  of  infancy.  The  degree  to  which  the 
paralysis  and  the  mental  afiection  are  found  in  different  cases  varies  from 
sanity  to  idiocy,  from  the  slightest  weakness  to  complete  paralysis, 
shrivelling,  and  shrinking  of  the  limbs.  The  pathology  of  those  cases  is 
very  interesting.  Often  the  convolutions  in  the  affected  hemisphere  are 
found  damaged  and  atrophied,  the  lower  ganglia  and  centres  undeveloped, 
and  one-half  of  the  spinal  cord,  as  well  as  the  motor  nerves  from  it  to 


STATES    OF    MENTAL    ENFEEBLEMEN  T.  215 

the  affected  side,  atrophied  or  not  developed.  I  have  never  been  able  to 
understand  why  cerebral  apoplexies  occur  in  infancy.  I  am  inclined  to 
think  that  they  are  often  not  effusions  of  blood,  but  vaso-motor  spasms 
from  neurotic  causes  affecting  certain  of  the  cerebral  vessels,  and  resulting 
in  trophic  damage  to  the  parts  of  the  brain  deprived  of  blood. 

The  inflammatory  idiocy  results  from  the  inflammations  and  sloughings 
that  affect  the  throat  and  ears  in  scarlet  fever  spreading  inwards  and 
damaging  the  brain.  Certain  portions  of  the  organ  are  usually  found  to 
be  hypertrophic  in  those  cases.     It  is  a  very  unfavorable  variety. 

The  traumatic  variety  is  much  like  the  inflammatory,  or  sometimes  like 
the  paralytic  form,  and  results  from  falls  and  blows  on  the  head. 

The  microcephalic  is  a  very  interesting  variety  of  idiocy.  On  the 
whole,  the  heads  of  idiots  are  smaller  than  those  of  sane  persons,  but 
there  are  many  exceptions  to  this  rule,  and,  as  a  matter  of  fact,  the 
average  sizes  of  the  heads  of  idiots  are  as  large  as  the  minimum  sizes  of 
perfectly  sane  persons.  Ireland  says  :  "  The  size  of  the  head  gives  no 
estimate  of  the  comparative  intelligence  of  the  (idiotic)  children."  There 
is,  however,  a  certain  minimum  size  below  which  a  head  is  incompatible 
with  average  intelliorence.  I  believe  a  circumference  of  below  eighteen 
inches  means  idiocy.  Very  typical  microcephalics  are  rare,  but,  when 
seen,  they  make  a  strong  impression.  They  look  so  impish  and 
unearthly.  They  are  usually  active,  alert,  mischievous,  imitative, 
intractable.  I  have  no  really  good  specimen,  but  E.  H.,-  with  a  head  of 
eighteen  inches  in  circumference,  a  small  face,  a  small  but  perfectly  well- 
formed  body,  an  active,  imitative  way,  and  a  restless  manner,  gives  an 
idea  of  one.  Her  only  deformity  is  a  cleft  and  acutely  arched  palate. 
She  just  looks  like  a  small  dried-up  woman,  with  small  features  and  a 
most  singular  expression  of  face,  and  she  smiles  as  if  a  baby  was 
imitating  the  features  of  an  old  woman.  Microcephalics  should  always 
be  sent  to  training  schools.  They  are  often  educable  up  to  a  certain 
point,  and,  if  not  educated,  they  are  often  little  demons.  Their  muscular 
activity  must  find  an  outlet. 

The  hydrocephalic  variety  of  idiocy  is  very  common,  but  I  need  hardly 
say  to  you  that  hydrocephalus  with  even  enormou^  enlargement  and  great 
deformity  of  the  head  is  perfectly  compatible  with  sanity.  It  usually  has 
a  dwarfing  and,  often,  a  defornjing  effect  on  the  body.  A  small  head  is 
no  proof  that  there  has  not  been  hydrocephalus. 

E.  I.  is  a  good  example  of  a  hydrocephalic  idiot.  She  is  now  ten,  and 
is  slow  in  her  movements,  very  gentle  and  patient,  sometimes  cries  and 
moans,  as  if  she  had  an  organic  sensation  of  discomfort  in  her  head. 
Her  head  is  globular,  the  fontanelles  raised,  the  temples  projected.  She 
looks  unhealthy,  has  scrofulous  glands,  and  a  feeble  constitution.  Her 
temper  is  good.  She  is  educable,  and  worth  educating.  I  am  going  to 
have  her  sent  from  this  to  an  imbecile  training  institution.  Drs.  Batty 
Tuke  and  Campbell  Clark  described  very  ftilly  the  condition  of  the  brain 
in  hydrocephalic  idiocy.  The  former  found  enormous  hypertrophy  of  the 
neuroglia,  and  the  latter  found  a  floating  lobe  or  portion  of  brain, 
unattached  to  any  other  nerve  tissue,  which  could  never,  therefore,  have 
exercised  nerve  functions,  yet  it  had  nerve  cells  and  fibres  in  a  primitive 
form. 


216  STATES    OF    MENTAL    ENFEEBLEMENT. 

Idiocy  may  occur  by  deprivation  of  the  senses  only.  The  famous  case 
of  Laura  Bridgman,  who  was  blind,  deaf,  and  dumb,  and  with  an  indis- 
tinct sense  of  smell,  but  with  common  sensation,  through  which  Dr. 
Howe  educated  her  brain,  developed  intelligence  and  emotion,  and 
raised  her  from  a  condition  of  absolute  idiocy  to  one  of  great  mental 
capacity,  is  and  will  always  be  the  classical  case  of  idiocy  by  deprivation. 
She  differed  essentially  from  most  other  forms  and  cases  of  idiocy  in 
having  a  brain  well  developed  and  apparently  normal  in  all  respects, 
excepc  that  its  inlets  and  outlets  were  obstructed.  Ordinary  deaf-mutism 
is  closely  allied  to  idiocy,  and  is  one  of  the  hereditary  neuroses.  To  me 
it  is  a  physiological  sin  that  marriages  between  such  persons  should  be 
legal. 

Cretinism  is  an  endemic  disease  occurring  in  connection  with  goitre  in 
some  valleys  of  mountain  chains,  such  as  the  Alps,  Cordilleras,  and 
Himalayas,  and  not  found  here,  so  I  need  say  nothing  about  it.  It 
is  very  interesting  from  an  etiological  and  pathological  point  of  view,  and 
has  quite  a  literature  of  its  own  on  the  Continent. 


LECTURE    VIII. 

STATES  OF  MENTAL  STUPOK  (PSFCHOCOMA). 

You  will  not  find  stupor  put  among  the  ordinary  symptomatological 
varieties  of  mental  diseases,  along  with  mania,  melancholia,  etc.  This  I 
think  is  a  mistake.  The  only  objections  to  its  being  so  placed  are  two — 
that  it  is  not  commonly  a  primary  disease ;  and  that  the  word  stupor 
does  not  imply  to  the  lay  or  even  to  the  medical  mind  any  necessary 
mental  disease  at  all,  as  they  understand  it.  But  these  objections  should 
not  prevent  us  using  the  word  to  express  in  a  correct  scientific  sense  a 
morbid  mental  condition,  which  is  different  psychologically  and  clinically 
from  all  other  morbid  mental  symptoms,  which,  while  it  lasts,  demands 
different  treatment  from  them  in  many  cases,  and  has  a  difierent  course 
and  termination.  Stupor  used  in  this  strict  medico-psychological  sense 
may  be  thus  defined :  "A  morbid  condition  in  which  there  are  mental  and 
nervous  lethargy  and  torpor,  in  which  impressions  on  the  senses  produce 
no  outward  present  effect,  in  which  the  faculty  of  attention  is  or  seems 
perfectly  paralyzed,  in  which  there  is  no  sign  of  originating  mental  power, 
in  which  the  higher  reflex  functions  of  the  brain  are  paralyzed,  and  in 
which  the  voluntary  motions  are  almost  suspended  for  want  of  convolu- 
tional  stimulus,  but  where  the  patients  usually  retain  the  power  of 
standing,  walking,  masticating,  and  swallowing." 

I  look  on  mental  stupor  as  essentially  the  expression  of  an  exhausted, 
lowered,  and  devitalized  brain. 

A  typical  case  of  this  condition  stands  for  hours  where  he  is  placed  in 
the  same  attitude,  when  spoken  to  he  takes  no  notice,  he  shows  no  active 
desires  or  affections,  he  does  not  speak  or  move,  or  show  any  interest  in 
anything.  His  expression  of  face  is  vacuous,  his  vaso-motor  power 
is  usually  much  below  normal  so  that  his  extremities  look  blue  and  are 
cold,  he  does  not  obey  the  calls  of  nature,  or  take  any  notice  of  them  at 
all.  Loud  sounds  make  no  impression,  pleasant  or  terrible  sights  that 
would  in  others  produce  motion  and  emotion  fail  to  do  so.  A  woman  once 
committed  suicide  by  hanging  herself  in  a  dormitory  at  Morningside  in 
the  presence  of  another  woman  in  a  condition  of  stupor,  who  took  no 
notice  whatever  of  this  frightful  sight. 

Looking  at  the  condition  of  stupor  from  the  point  of  view  of  the  phy- 
siology of  the  brain,  we  see  that  its  power  of  receiving  impressions  from 
without  is  in  abeyance,  and  its  higher  reflex  functions  are  suspended. 
The  mental  and  motor  irritation  of  a  full  bladder  or  loaded  rectum  is  not 
felt  by  the  higher  brain  centres ;  and  when  through  the  action  of  the 
lower  centres,  evacuations  take  place,  there  is  either  no  consciousness  on 
the  part  of  the  higher  centres,  or,  if  there  is,  it  does  not  result  in  the 
volition  that  prepares  suitably  for  them,  or  in  the  vexation  that  would  be 


218  STATES    OF    MENTAL    STUPOR. 

felt  in  health,  if  they  took  place  over  the  body.  Even  the  ordinary  skin 
and  spinal  reflexes  are  much  diminished  or  abolished.  The  appetites  for 
food  and  drink  are  paralyzed,  or  if  felt  are  not  followed  by  any  exertion  to 
satisfy  them. 

A  striking  exception,  and  the  only  material  exception  to  the  passivity 
or  suspension  of  brain  function  in  stupor  is  regard  to  the  reproductive 
instinct  in  a  low  morbid  form.  In  the  first  place,  most  of  the  typical 
cases  of  stupor  occur  in  the  actively  reproductive  period  of  life.  Most 
of  them,  in  fact,  are  under  thirty.  Dr.  Hack  Tuke^  found  that  twenty- 
seven  was  the  average  age  in  twenty  cases.  In  my  experience  all  the 
Tery  typical  cases  are  nearer  twenty  than  thirty.  In  by  far  the  majority 
of  the  cases,  the  commencement  of  the  disease  had  been  connected  with 
or  accompanied  by  a  sexual  excitation  in  some  form  or  other.  Many  of 
them  had  indulged  in  the  habit  of  masturbation  to  a  very  morbid  extent 
indeed,  and  had  exhausted  the  brain  energy  thereby,  had  "  stupefied  " 
themselves,  in  fact,  by  this.  Most  of  them  indulged  in  this  habit  long 
after  they  had  entered  into  a  condition  of  mental  stupor,  doing  it  auto- 
matically rather  than  volitionally,  and  many  of  them  have  sexual 
delusions  at  the  expiration  of  the  attack. 

Many  of  these  girls  had  been  hysterical,  and  showed  during  their  dis- 
ease marked  hysterical  symptoms.  The  aspect,  expression  of  eyes,  and 
behavior  before  the  other  sex,  while  consciousness  existed,  were  markedly 
erotic,  this  being  so  in  some  of  the  cases,  even  after  speech  and  all 
outward  mental  manifestations  had  ceased.  Many  of  them  have  catalep- 
tic, trance,  and  hystero-epileptic  symptoms,  all  these  affections  being  most 
strongly,  in  my  opinion,  connected  with  the  ftinction  of  reproduction,  its 
disorders,  or  its  perversions.  The  direct  connection  of  stupor  in  most 
cases  with  the  reproductive  and  sexual  functions  has  not  been  sufficiently 
considered  hitherto.  I  look  on  those  functions  as  the  dominant  vital 
activities  from  adolescence  to  thirty-five  in  many  persons  of  the  neurotic 
diathesis.  If  the  inherent  brain  stability  is  hereditarily  weak,  with  the 
inhibitory  powers  poorly  developed,  and  if  under  those  circumstances 
there  is  much  intense  sexual  excitement  or  a  constant  sexual  drain 
through  masturbation  or  sexual  intercourse,  stupor,  in  some  form  or 
degree,  is,  in  my  opinion,  the  natural  expression  of  the  exhaustion  of  the 
higher  nerve  force  that  follows.  We  shall  see  examples  to  prove  this 
presently. 

When  I  thus  bring  out  strongly  the  connection  of  stupor  with  the 
reproductive  function,  it  must  be  remembered  that  I  am  referring  par- 
ticularly to  that  form  which  is  attended  by  unconsciousness,  though  this 
may  have  a  distinctly  melancholic  stage  or  tinge  throughout  (mental 
depression  too  being  a  symptom  of  brain  exhaustion) ;  and  it  must  be 
kept  in  mind  that  there  are  cases  of  stupor  of  the  melancholic  type 
resulting  from  other  causes,  such  as  mental  or  nervous  shocks,  frights, 
losses,  or  bodily  diseases,  which  have  no  reproductive  or  sexual  complica- 
tion at  all. 

The  voluntary  motor  system  is  found,  on  examination,  to  be  in  three 
conditions  in  different  cases  or  in  different  stages  of  the  same  case,  viz., 

*  International  Medical  Congress,  1881,  Transactions,  vol.  iii.  p.  638. 


STATES    OF    MENTAL    STUPOR.  219 

(1)  quite  passive,  unresistive,  and  having  no  tendency  to  keep  fixed  posi- 
tions ;  (2)  cataleptic,  with  decided  tendencies  to  keep  fixed  attitudes  and 
positions,  but  with  no  resistance  to  external  force  used  in  changing  the 
muscular  positions;  (3)  resistive,  showing  a  more  or  less  strong  resist- 
ance to  external  efforts  to  change  the  position.  The  first  is  commonly 
found  in  the  anergic  form  of  stupor,  especially  when  it  is  caused  by  a 
previous  acute  attack  by  masturbation,  general  paralysis,  or  alcohol ;  the 
second,  also,  in  some  of  the  anergic  reproductive  cases;  and  the  last  in 
the  melancholic  form  alone. 

Looked  at  from  the  purely  mental  point  of  view,  conditions  of  stupor 
are  divisible  into  three  varieties,  viz.,  the  unconscious — the  anergic — 
where  consciousness  and  memory  are  gone ;  and  the  conscious — the 
melancholic — where  they  are  both  present,  and  where  there  is  a  delusion 
present,  these  facts  being  ascertained  and  tested  afterwards  by  the 
patient's  own  account ;  and  the  half-conscious  or  confused,  where  there  is 
some  consciousness,  but  by  no  means  a  keen  or  a  correct  subjective 
realization  of  events,  and  where  the  recollection  of  them  afterwards  is 
confused  or  delusional.  Some  cases  pass  through  all  these  conditions  in 
different  stages.  Conditions  of  mental  stupor  have  excited  much  interest, 
and  have  an  extensive  literature,  especially  in  France,  to  which  of  course 
I  have  no  time  to  refer.  Mr.  Hayes  Newington,  when  assistant  physi- 
cian at  Morningside  in  1874,  studied  them  carefiilly,  and  wrote  a  capital 
description^  of  them,  with  which  I  in  the  main  agree;  indeed,  all  must 
agree  with  him,  for  he  sticks  closely  to  clinical  fact.  He  gave  us  the 
admirable  word  '"'■anergic"  to  describe  the  passive,  unconscious,  non- 
depressed  cases.  This  should  take  the  place  of  the  older  term  Acute 
Dementia,  still  commonly  applied  to  such  cases.  It  should  certainly  be 
discontinued,  for  it  is  confusing  and  incorrect.  If  you  take  a  typical 
case  of  either  the  melancholic  or  the  anergic,  each  undoubtedly  cor- 
responds to  his  descriptions;  but  an  extended  clinical  experience  has 
shown  me  that  the  same  case  may  begin  by  being  in  the  condition  of 
melancholic  and  conscious  stupor,  and  may  end  by  being  in  the  anergic 
and  unconscious.  Then  I  find  that  by  far  the  greater  number  of  the 
cases  that  were  anergic  during  the  greater  part  of  their  course  had  a  short 
melancholic  stage  to  begin  with.  As  for  stupor  being  a  primary  affec- 
tion I  call  to  mind  very  few  cases  where  it  was  entirely  so.  It  scarcely 
ever  begins  as  stupor.  There  is  a  stage  of  mental  depression  or  of 
mania,  very  short,  it  may  be,  but  still  present.  The  stupor  may  have 
been  the  disease  for  all  practical  and  clinical  purposes,  but  still  the 
initiatory  stage  of  another  condition  was  there.  The  cases  which  we 
shall  see,  or  to  which  I  shall  refer,  will  illustrate  those  various  points  of 
causation  and  symptoms. 

The  best  clinical  division  of  stupor  would  be,  I  think,  into  the  following 
kinds ;  which,  in  the  order  of  their  frequency  or  importance,  are : 
a.  Melancholic  stupor. 
h.  Anergic  stupor. 

c.  Secondary  stupor  (transitory  after  acute  mental  disease). 

d.  General  paralytic  stupor. 

e.  Epileptic  stupor. 

*  Journal  of  Mental  Science,  October,  1874. 


220  STATES    OF    MENTAL    STUPOR. 

Melancholic  Stupor  is  by  far  the  most  frequent  and  the  most 
important  form.  It  is  the  melancliolia  attonita,  or  the  melandiolie  avec 
stupeur  of  the  authors.  As  I  have  said,  it  is,  either  throughout  its  whole 
course,  or  at  some  part  of  it,  the  conscious  and  delusional  form  or  the 
half-conscious  looked  at  from  the  mental  point  of  view,  the  resistive 
looked  at  from  the  volitional  muscular  aspect,  and  the  non-paralytic 
looked  at  from  the  vaso-motor  point  of  view.  Some  authors  write  as  if 
there  w^as  always  one  overmastering  delusion  of  a  terrible  kind,  the 
patient  fancying  himself  dead,  or  that  he  is  too  wicked  to  hold  intercourse 
with  his  fellow-men,  or  that,  if  he  speaks,  he  will  be  killed,  which,  as  it 
were,  fills  the  whole  mental  vision,  and  leaves  no  room  for  any  other 
manifestation  of  mind,  paralyzing  speech  and  active  volition  of  any  kind. 
I  do  not  think  this  a  true  view  to  take.  There  may  or  there  may  not  be 
such  a  delusion,  but  by  itself  a  delusion  never  causes  stupor.  There 
must  be  something  more  than  this.  There  is  always  in  addition  a  dis- 
tinct morbid  condition  of  the  brain  aifecting  its  reflex  action,  its  trophic 
energy,  its  receptive  power  in  all  directions,  and  most  especially  its  active 
ideo-motor  functions.  None  of  these  things  are  the  concomitants  of 
merely  delusional  conditions.  I  look  on  the  delusion  as  one  symptom 
only,  and  not  the  cause  of  the  melancholic  stupor.  Melancholic  cases  are 
sometimes  suddenly  impulsive  at  one  period  of  the  disease,  and  it  is  well 
to  remember  that  during  convalescence  they  may  be  suicidally  impulsive. 
Gusts  of  motor  energy  seem  suddenly  to  be  evolved  in  the  brain.  I 
have  seen  epileptiform  fits  occur  occasionally  in  such  cases,  but  much 
more  frequently  a  condition  merely  simulating  epilepsy  or  apoplexy,  the 
patient  being  conscious  and  having  control  over  the  muscular  move- 
ments. Whenever  you  see  a  melancholic  patient  said  to  be  "in  a  fit," 
always  think  of  this  condition.  It  is  very  common.  In  some  instances 
this  state  occurs  as  the  acme  of  an  ordinary  case  of  delusional  or  excited 
melancholia,  being  a  short  incident  in  the  case.  In  other  instances, 
though  preceded  by  depression  of  mind,  the  stupor  is  the  chief  part  of 
the  disease.  In  some  instances  the  stupor  remains  characteristically 
melancholic  all  through — being  conscious,  resistive,  and  unaccompanied 
by  vaso-motor  paralysis.  In  other  instances  it  passes  into  anergic 
stupor — the  patient  being  unconscious,  unresistive,  and  with  vaso-motor 
and  trophic  paresis.  Some  cases  of  melancholic  stupor  assume  melan- 
cholic attitudes.  Here  is  a  young  woman  who  lies  flat  on  the  ground, 
with  her  face  on  the  floor,  and  she  resists  being  placed  on  a  chair.  Here 
is  a  young  man  who  is  bent  down  till  he  almost  crouches.  Here  is 
another  who  puts  his  fingers  to  his  ears  and  keeps  them  there.  The 
following  are  three  cases  of  melancholic  stupor,  the  first  two  (F.  M.  and 
F.  N.)  being  patients  of  the  ordinary  type,  and  the  third,  F.  0.,  being 
a  very  extraordinary  case  in  its  severity,  duration,  and  length  of  time  he 
was  artificially  fed,  and  in  its  termination  in  recovery  in  these  circum- 
stances : 

F.  M.,  set.  21,  a  well-educated,  bright,  clever,  and  industrious  youth 
of  sanguine  temperament.  No  nervous  heredity  admitted.  Habits  tem- 
perate and  correct.  The  cause  of  the  attack  was  over-study  when  he  was 
rapidly  developing  in  body,  and  had  not  attained  manhood.  His  brain 
was  exhausted  by  the  body  function,  growth,  development,  want  of  sleep, 


STATES    OF    MENTAL    STUPOR.  221 

and  continuous  mental  effort.  His  first  symptoms  began  eighteen  months 
ago,  and  were  mental  depression,  sleeplessness,  and  pain  in  the  head. 
He  got  worse  in  mind  and  body,  and  soon  became  suicidal — attempting 
to  take  away  his  life.  He  became  suspicious  too,  his  affection  for  his 
relations  diminishing,  and  he  was  fickle.  He  then  got  so  much  better 
through  rest  and  change  that  he  resumed  his  work  and  studies.  When 
he  relapsed,  a  few  weeks  before  admission,  he  became  again  very  suicidal 
— asking  for  poison,  and  wanting  to  drown  himself.  His  motive  for 
suicide  was  that  people  were  going  to  kill  him.  On  admission  he  was 
much  depressed,  though  he  could  pick  himself  up  and  smile  in  a  forced 
way.  He  was  very  suspicious,  imagining  that  he  had  done  some  great 
crime,  and  that  he  w^as  to  be  tried  and  Avould  be  hanged.  He  was  thin, 
his  muscles  flabby,  his  pulse  sixty  and  weak,  bowels  constipated.  Tem- 
perature— 97.2°  in  the  morning,  96.4°  at  night.  Weight,  nine  stone  ten 
pounds.  He  was  unsettled  and  restless  at  night  as  well  as  being  sleepless. 
His  appetite  was  poor.  He  was  evidently  all  the  time  looking  for  the  means 
of  suicide,  so  he  was  carefully  attended  night  and  day.  He  got  more 
confused  and  more  obstinate,  until  in  a  fortnight  after  his  admission  he 
was  in  a  state  of  complete  stupor ;  his  countenance  wore  a  heavy  semi- 
vacuous,  semi-depressed  expression ;  he  would  not  answer  questions  or 
take  notice  of  anything ;  was  utterly  careless  of  his  dress  and  person, 
letting  his  motions  pass  where  he  stood.  The  skin  had  a  warm  clammy 
feel,  except  at  the  extremities,  which  were  blue  and  cold.  He  had  a  few 
lucid  intervals  of  a  few  minutes  each,  when  he  would  as  it  were  wake  up 
and  ask  Avhere  he  was.  The  treatment  from  the  beginning  consisted  of 
his  being  compelled  to  take  an  enormous  quantity  of  milk  and  eggs  in 
liquid  custards,  flavored  with  nutmeg,  and  with  half  a  glass  of  sherry  in 
each.  He  took  usually  in  the  day  twelve  eggs  and  six  pints  of  milk, 
and  began  to  gain  in  weight  after  the  first  fortnight.  He  had  quinine 
and  strychnine  in  moderate  doses,  and  cod-liver  oil  emulsion,  containing 
hypophosphite  of  lime  and  pepsine.  He  was  walked  in  the  open  air  a 
great  deal.  His  skin  was  well  rubbed  with  rough  towels  night  and 
morning,  and  occasionally  he  had  the  continued  current  up  to  fifteen 
cells.  He  steadily  gained  in  weight.  After  three  months'  treatment  he 
began  to  speak,  and  wrote  the  following  letter  to  his  mother:  "My 
mother,  please  let  me  go  home.  I  don't  know  where  I  am.  I  feel  very 
ill.  Would  you  let  me  go  home."  In  a  few  days  he  wrote  to  her  to 
send  him  some  money  to  pay  for  his  maintenance  here,  saying  that  he 
thought  about  .£3000  would  do,  that  he  was  a  nuisance  to  those  round 
him,  and  asking  what  great  crime  he  had  committed,  and  requesting  that 
he  might  be  punished  adequately.  In  another  month  the  confusion  of 
mind  was  passing  away  ;  in  a  month  from  that  he  was  practically  well  in 
reasoning  power,  in  feeling,  memory,  and  in  bodily  health,  and  was  over 
eleven  stone  in  Aveight.  He  was  bright,  intelligent,  lively,  and  a  great 
favorite.  He  said  he  remembered  in  a  confused  way  the  events  that 
occurred  during  his  period  of  stupor,  that  he  had  the  delusion  all  the 
time  he  had  committed  a  crime,  and  was  to  be  punished,  and  could  not 
pay  for  the  food  given  to  him.  When  discharged,  six  months  after 
admission,  I  never  was  more  satisfied  in  any  case  that  a  complete  recovery 


222  STATES    OF    MENTAL    STUTOR. 

had  been  made.  I  always  like  to  see  a  patient  get  fat  on  recovery  from 
any  form  of  insanity. 

This  was  a  very  typical  case  of  melancholic  stupor,  showing  well  how 
the  stupor  was  the  acme  of  the  brain  condition,  which  showed  itself  first 
as  melancholia,  how  there  was  a  melancholic  tinge  through  the  stupor, 
and  a  distinct  melancholic  delusion.  But  I  conceive  it  would  be  a  mis- 
take to  describe  the  stupor  as  being  caused  by  a  profound  delusion.  As 
a  matter  of  fact,  in  this,  as  in  all  such  cases,  the  intensity  of  realization 
of  the  delusion,  and  the  capacity  to  feel  keenly,  were  blunted  by  the  con- 
dition of  stupor.  The  stupor  I  look  on  as  a  brain  condition  distinct 
altogether  from  that  of  acutely  felt  depression  in  melancholia,  in  which 
delusions  are  vivid,  and  the  misery  profound.  We  find  that  delusions 
alone  never  cause  stupor,  whatever  their  character.  They  may  cause 
prolonged  taciturnity  for  years,  but  this  is  totally  different  from  stupor. 
The  condition  of  the  mental  portion  of  the  convolutions  in  stupor  is 
analogous  to  the  stupidity  of  a  nervous  child  when  terrified  or  bullied. 
I  do  not  see  any  but  a  superficial  analogy  betAveen  stupor  of  any  kind 
and  hypnotism. 

The  following  was  a  case  of  melancholic  stupor  of  short  duration,  and 
with  a  complete  recovery  : 

F.  N.,  aet.  35.  Temperament  melancholic.  Habits  intemperate ;  a 
prostitute.  Heredity — mother  intemperate,  and  subject  to  periodic 
attacks  of  melancholia.  Her  illness  began  by  melancholic  depression 
and  delusions,  but  she  soon  became  excited,  noisy,  and  tried  to  commit 
suicide.  She  had  no  great  overmastering  melancholic  delusion  to  account 
for  the  stupor  into  which  she  soon  passed  after  admission,  which  was 
complete  with  all  the  characters  of  melancholic  stupor ;  muscularly 
resistive,  no  cataleptic  tendency,  refusal  of  food,  and  expression  of  face 
depressed.  She  would  not  walk  or  move,  and  had  to  be  kept  in  bed. 
She  remained  in  that  state  for  about  six  weeks.  It  was  evidently  the 
acme  of  the  attack  of  melancholia,  and  she  shortly  got  better  and  made 
a  good  recovery  in  six  months.  She  now  says  that  the  period  of  stupor 
was  a  blank  to  her,  and  she  remembers  nothing  that  took  place  then. 

The  following  was  a  case  of  prolonged  melancholic  delusional  stupor, 
lasting  three  years,  simulating  "acute  dementia,"  and  requiring  artificial 
feeding  all  that  time,  with  final  recovery. 

F.  0.,  set.  31.  Admitted  26th  January,  1876.  Disposition  retiring. 
Strumous  diathesis.  Habits  unsocial,  and  almost  too  industrious  and 
sedentary.  Excessive  masturbation.  Father  intemperate ;  mother  died 
of  consumption.  Had  one  slight  attack  of  mental  disease  (melancholia) 
three  years  ago,  from  which  he  quite  recovered  in  a  few  months.  First 
symptoms  of  mental  disease  were  slight  depression  and  foolish  fancies. 
Along  with  these  there  were  sleeplessness,  pains  in  head,  loss  of  nutrition, 
and  great  coldness  of  extremities.  Sometimes  he  could  not  be  kept  warm 
by  any  means  used.  Was  not  dirty,  destructive,  or  obscene,  nor  violent. 
Those  symptoms  showed  themselves  fifteen  months  ago.  As  he  got 
worse,  he  opened  a  vein,  and  lost  some  blood,  and  on  several  other 
occasions  he  seemed  to  have  tried  to  choke  himself  with  a  scarf.  He 
was  at  times  noisy  and  incoherent,  and  quite  sleepless.  He  had  changing 
delusions,  e.  g.,  that  his  brain  was  compressed  by  an  evil  spirit. 


STATES    OF    MENTAL    STUPOR.  223 

On  admission  he  was  depressed  and  hypochondriacal,  fancying  that  he 
was  dangerously  ill,  that  he  had  been  a  great  sinner  and  very  licentious, 
that  he  suffered  shame  more  than  all  mankind,  and  that  his  body  had 
been  tampered  with  when  he  had  attempted  suicide.  Along  with  the 
depression  there  were  much  mental  enfeeblement,  facility,  childishness, 
and  impairment  of  memory,  with  rambling  and  incoherence.  He  had 
delusions  about  his  sexual  organs.  He  was  anaemic,  flabby,  thin,  and  we 
thought  that  there  was  slight  comparative  dulness  at  apex  of  right  lung, 
with  rough  breathing  sounds.  Temperature,  98.4°.  Height,  five  feet 
six  and  a  half  inches.     Weight,  eight  stone  thirteen  pounds. 

He  remained  very  much  in  this  mildly  melancholic  condition  for  three 
months.  He  constantly  wanted  quack  medicines,  had  a  poor  appetite,  and 
used  to  twist  and  wriggle  his  body  about  in  obedience  to  delusions.  He 
then  had  an  attack  of  deeper  depression,  with  more  confirmed  delusions, 
intense  insane  obstinacy,  impulsive  violence,  shouting  at  times  and  twist- 
ing his  body  about,  as  if  there  were  beasts  crawling  on  him.  After  this 
he  refused  food  entirely  in  May,  and  was  fed  with  the  stomach-pump  on 
May  7,  1876,  resisting  strongly.  He  took  his  food  on  the  17th,  but 
again  needed  to  be  fed  on  the  18th,  and  for  several  weeks  afterwards. 
Then  for  several  months  he  took  his  food  himself,  his  mental  condition 
otherwise  remaining  much  as  before,  and  his  delusions  being  very  pro- 
nounced. But  in  May,  1877,  he  again  began  to  refuse  food,  and  from 
that  time  till  April  30,  1880 — a  period  of  over  two  years  and  eleven 
months — he  took  no  food,  and  required  to  be  fed  twice  a  day  with  the 
stomach-pump. 

But  this  was  not  the  most  extraordinary  part  of  his  case.  In  the 
course  of  a  month  after  his  being  fed,  he  had  got  into  a  condition  of 
absolute  stupor,  lying  motionless,  insensible  to  pain,  unable  to  stand,  his 
urine  and  feces  dribbling  away,  his  circulation  feeble,  offering  no  resist- 
ance to  anything  done  to  him,  and  taking  no  notice  apparently  of  any- 
thing. Nothing  could  rouse  him,  nothing  could  stir  him,  nothing  could 
excite  any  mental  or  bodily  reply  or  response,  except  that  he  shut  his 
eyes  tightly  when  the  eyeballs  were  touched,  and  there  was  slight  motion 
of  the  legs  when  the  soles  of  his  feet  were  tickled.  But  this  last  reflex 
power  disappeared  in  October,  1878.  Much  difiiculty  w^as  experienced  in 
keeping  him  warm,  but  an  old  and  most  affectionate  maiden  aunt,  who 
came  to  see  him  almost  daily,  contrived  the  most  wonderful  woollen  foot 
coverings  and  body  rugs.  He  was  dressed  in  the  morning,  carried  down 
to  a  sofa,  and  his  penis  inserted  into  an  India-rubber  bottle.  There  he 
lay  all  day,  never  moving,  never  resisting  anything  done  to  him.  He 
seemed  the  most  complete  case  of  "acute  dementia"  or  anergic  stupor  I 
ever  saw,  except  for  two  things :  these  were,  a  certain  expression  in  his 
face,  which  was  never  so  absolutely  blank  as  it  is  in  that  condition,  and 
his  not  being  able  to  stand  or  move  at  all,  which  seldom  occurs.  There 
was  none  of  the  resistance  or  muscular  rigidity  of  melancholic  stupor. 

As  regards  treatment,  he  was  fed  in  the  morning  with  a  liquid  mess, 
consisting  of  a  pound  of  beef  done  to  a  liquid  form  in  a  large  mortar  with 
potatoes  and  vegetables  similarly  pounded  down,  the  whole  being  made 
liquid  enough  to  pass  readily  through  a  stomach-pump  tube  with  beef-tea 
and  a  quarter  of  a  pound  of  sugar.    In  the  evening  he  had  a  custard  with 


224  STATES    OF    MENTAL    STUPOR. 

three  eggs  and  a  quarter  of  a  pound  of  sugar.  His  bowels  kept  regular. 
He  had  at  various  times  quinine,  strychnine,  phosphorus,  ergot,  cod-liver 
oil,  the  hypophosphite  of  lime,  iron,  and  the  continued  current  up  to 
twenty  cells  of  a  Hawksley's  battery,  used  once  a  day  for  months  together, 
through  his  brain  and  spinal  cord.  No  good  seemed  to  be  done,  yet  he 
was  a  case  about  whom  we  never  quite  lost  hope.  His  nutrition  kept  fair, 
and  he  did  not  lose  weight. 

At  last,  in  June,  1879,  he  was  observed  by  his  attendant  to  turn  over 
on  the  sofa.  Then  reflex  action  on  tickling  of  the  soles  was  observed, 
and  his  countenance  began  to  acquire  more  expression.  The  continued 
current  was  being  used  at  this  time,  but  I  am  very  doubtful  if  it  had  any- 
thing to  do  with  his  improvement.  In  February,  1880,  his  glottis  became 
more  sensitive,  so  that  the  passage  of  the  tube  caused  coughing,  and  he 
raised  himself  up  after  feeding  once.  One  day  he  seized  the  tube  and 
remained  rigid  and  cataleptic  for  a  few  minutes.  On  April  30,  1880,  he 
spoke  for  the  first  time,  and  at  feeding  time  said  he  was  tired  of  custards, 
and  wanted  some  tea,  took  a  moderate  tea  and  supper,  and  a  good  break- 
fast. He  had  never  lost  weight  during  all  the  time  of  his  artificial  feed- 
ing. He  took  no  food  on  May  1st,  but  on  May  2d  asked  Dr.  Clark, 
who  was  about  to  feed  him,  if  it  was  the  custom  to  keep  sane  men  in  the 
asylum,  and  on  being  told  that  it  was  not  much  like  a  sane  man  to  refuse 
food,  he  replied,  "Then  if  I  take  my  food  will  that  prove  my  sanity?" 
"Yes."  "Then  give  it  me  at  once."  He  took  it  there  and  then,  and 
never  missed  a  meal  afterwards.  He  was  weak  and  his  appetite  was 
feeble,  but  he  soon  began  to  walk,  then  to  go  out,  and  he  got  stronger, 
and  heavier  by  nearly  a  stone  than  he  was  on  admission.  When  asked 
about  his  stupor,  he  always  gave  some  sexual  reason  such  as  that  it  was 
"gonorrhoea"  or  "emissions"  that  had  been  the  cause  of  it.  He  asserted 
that  he  had  been  conscious  all  the  time,  and  made  some  statements  which 
proved  that  there  had  been  some  consciousness,  reasoning  power,  and 
memory.  He  described  how  a  sphygmograph  was  used  on  his  radial 
artery,  he  told  the  names  of  assistant  physicians  who  had  been  in  charge 
of  him  during  his  stupor,  and  he  "asked  pardon  for  my  conduct."  His 
memory  was  not  quite  clear  however ;  he  could  not  tell  much  about  what 
happened,  nor  the  year  he  entered  the  asylum.  His  memory  of  events 
before  his  illness  was  good,  and  he  showed  much  curiosity  as  to  what  had 
been  going  on  in  the  religious  world.  He  was  hypochondriacal,  notional, 
and  somewhat  weak-minded,  and  was  discharged  relieved  on  June  21, 
1880.  He  has  improved  still  further  at  home,  his  old  maiden  aunt 
thinking  him  as  well  as  ever  he  was  in  his  life,  and  considering  him  a 
most  intelligent  and  exemplary  youth.  She  takes  almost  the  entire  credit 
of  his  resurrection,  a  distinction  which  I  am  much  inclined  to  award  to 
her,  for  she  kept  him  warm,  she  kept  up  the  interest  of  every  one  in  his 
case,  and  she  never  despaired  of  his  recovery. 

This  was  essentially  a  case  of  melancholic  stupor  (melancholia  attonita, 
pyschocoma,  melancholic  avec  stupeur),  with  many  of  the  features  of 
"anergic  stupor."  In  fact,  after  the  symptoms  attained  their  greatest 
intensity,  when  there  was  no  apparent  consciousness,  no  attention,  no 
muscular  resistance,  no  voluntary  motion,  and  no  spinal  reflex  function, 
■when  the  body  temperature  was  very  low,  the  capillary  circulation  in  the 


STATES    OF    MENTAL    STUPOR.  225 

extremities  was  very  weak,  the  urine  and  feces  passing  involuntarily  and 
at  all  times,  I  considered  the  case  as  one  of  anergic  stupor  (acute  de- 
mentia) that  had  arisen  at  first  out  of  a  melancholic  condition,  and  used 
to  speak  of  it  as  such,  a  fact  of  which  the  patient  reminded  me  after  his 
recovery.  I  certainly  did  not  think  there  was  consciousness,  or  attention, 
or  memory  really  present,  as  the  patient's  recollections  afterwards  proved 
them  to  have  been  to  some  extent.  In  old  times  the  case  would  have 
been  called  one  of  trance,  and  there  were  many  of  the  features  of  what 
is  now  described  in  the  books  by  that  name.  I  think  it  probable  that 
most  cases  of  trance,  if  examined  by  an  alienist,  would  be  placed  under 
melancholic  or  anergic  stupor.  It  will  be  noted  how  well  the  digestive 
and  trophic  functions  of  the  body  were  performed  when  there  was  no 
voluntary  muscular  action  whatever.  The  great  length  of  time  during 
which  the  symptoms  lasted,  and  the  final  recovery,  so  far  as  the  stupor 
was  concerned,  are  very  marked  features  of  the  case,  if  they  are  not 
unprecedented. 

The  following  was  a  striking  case  of  stupor  (melancholic)  following  a 
mental  shock: 

F.  T.,  aet.  55,  of  a  melancholic  temperament,  and  steady  and  indus- 
trious habits,  through  which  he  had  made  and  saved  £6000.  There  was 
no  known  neurotic  heredity.  He  was  a  shareholder  in  the  City  of  Glasgow 
Bank,  and  the  failure  of  that  ill-fated  concern,  and  the  loss  of  all  his 
money,  seemed  to  "take  the  spirit  out  of  him"  completely.  He  became 
sleepless,  nervous,  and  much  depressed.  He  lost  weight  from  fourteen 
stone  to  ten  stone  four  pounds.  He  first  spoke  constantly  about  his  being 
victimized  and  cheated,  and  then  expressed  delusions  that  he  was  in  debt, 
and  that  he  must  go  to  the  police  office  and  give  himself  up.  His  delu- 
sions by  and  by  referred  to  his  body  (no  doubt  his  organic  sensations,  as 
he  got  thin,  weak,  dyspeptic,  and  costive,  were  those  of  discomfort),  saying 
that  his  inside  was  burnt  up.  On  his  admission  to  the  asylum,  six  months 
after  the  beginning  of  his  disease,  he  was  with  difficulty  got  to  speak,  to 
answer  questions,  or  to  take  food;  and  he  slept  badly.  He  would  appear 
as  if  he  was  to  speak  or  answer  a  question,  but  the  volitional  power  to 
articulate  seemed  to  fail  him,  and  he  would  say  nothing.  His  next 
delusion  was  natural  enough,  the  wish  being  father  to  the  thought.  He 
fancied  he  was  dead,  and  he  would  say  "  I  am  dead ;  put  me  in  my 
grave."  Then  for  two  months  his  stupor  was  complete,  with  no  outward 
expression  of  mentalization  at  all.  But  the  expression  of  face  was; 
melancholic  as  well  as  stupid,  and  there  was  muscular  resistance.  He^ 
lay  in  bed.  All  this  time  he  was  getting  weaker.  No  tonics  excited  his 
appetite,  no  stimulant — and  he  got  brandy  in  large  quantities — roused 
him,  and  his  food  did  not  nourish  him.  The  news  of  his  favorite 
daughter's  death  did  not  affect  him.  I  have  no  doubt  he  had  the  delu- 
sion he  Avas  dead.  He  got  thinner  and  weaker,  and  gangrene  of  his  heel 
appeared,  then  hypostatic  pneumonia,  and  lastly  gangrene  of  the  lungs, 
of  which  he  died  eight  months  after  admission.  In  the  last  month  of  his 
life,  and  especially  when  his  temperature  rose  to  102.5°  from  the  lung 
disease,  he  would  answer  questions  at  times,  and  once  or  twice  spoke 
sensibly,  asking  what  sort  of  a  night  he  had  had,  but  generally  he  wantecj 
to  be  put  in  his  grave  and  "buried." 

15 


226  STATES    OF    MENTAL    STUPOR. 

At  the  post-mortem  examination  we  found  considerable  atrophy  of  the 
convolutions,  and  congestion  of  the  brain  substance. 

No  dramatist  ever  drew  a  more  vivid  picture  of  adversity  overwhelm- 
ing a  man,  striking  him  dumb,  crushing  the  whole  vitality  of  mind  and 
body  out  of  him,  and  soon  killing  him  outright. 

This  case  brings  out  strikingly  the  lowered  and  devitalized  condition 
of  the  brain,  which  I  look  on  as,  after  all,  the  proximate  cause  of  mental 
stupor. 

Anergic  Stupor  (Acute  Dementia). — This  may  be  a  primary  dis- 
ease commencing  without  any  melancholic  or  maniacal  stage,  though  I 
have  never  met  with  a  case  in  which  I  could  not  discover  at  least  a  trace 
of  these  conditions  at  the  beginning  of  the  attack.  Its  symptoms  are 
complete  unconsciousness,  and  of  course  no  after  memory  of  events  that 
occurred  during  its  persistence  ;  no  delusions ;  no  muscular  resistance ; 
but  in  some  cases  a  static  or  cataleptic  muscular  condition  ;  a  loss  of  facial 
expression  ;  a  marked  vaso-motor  paresis,  so  that  the  extremities  are  blue 
and  cold ;  a  lowering  of  the  trophic  energy,  so  that  sores  are  apt  to  form 
and  even  gangrene  may  occur;  the  reflex  functions  of  the  cord  are 
markedly  diminished,  and  the  higher  reflex  functions  of  the  brain  almost 
in  abeyance. 

The  following  case,  F.  P.,  w^as  one  of  anergic  stupor,  occurring  in  a 
girl  of  eighteen,  who  had  had  two  slight  attacks  of  melancholia  on  pre- 
vious occasions.  One  grandfather  had  been  melancholic  with  delusions, 
but  not  in  an  asylum ;  father  had  several  epileptic  attacks,  and  had  been 
very  "excitable"  after  each;  sister  became  "dazed"  after,  and  in  con- 
sequence of,  mother's  death  and  died  of  phthisis  in  four  months ;  and  a 
brother  was  eccentric  and  foolish.  Masturbation  suspected.  The  attack 
began  by  a  short  maniacal  stage,  with  much  incoherence,  "  laughing  in  a 
childish  way."  This  passed  into  a  condition  of  stupor  in  two  months, 
during  the  continuance  of  w^hich  she  never  spoke,  and  stood  in  one  posi- 
tion, or  sat  where  she  was  placed.  She  swallowed  liquid  food  when  put 
into  her  mouth,  but  showed  no  desire  for  anything  or  interest  in  anything. 
Loud  noises  near  her  did  not  startle  her.  She  did  not  obey  the  calls  of 
nature.  She  was  cold,  her  feet  blue  and  swollen,  her  pulse  weak  and 
quick,  and  the  reflex  function  of  spinal  cord  abolished.  There  was  no 
muscular  resistance  and  no  catalepsy.  After  about  a  month  she  seemed, 
under  the  use  of  stimulants,  nerve  tonics,  and  blisters  to  the  occiput,  to 
improve  somewhat,  but  she  soon  fell  back  again,  and  remained  ill  for 
over  a  year.  Menstruation,  which  had  been  absent  for  the  first  six 
months,  returned,  and  she  seemed  to  be  none  the  better  for  it.  As  she 
began  to  improve  she  got  a  little  obstinate  and  even  violent,  and  her 
brain  was  for  a  time  in  the  repeating  state  one  sees  sometimes  in  certain 
cases  of  mental  disease.  When  asked  a  question  she  would  repeat  the 
words  said,  or  part  of  them,  like  a  parrot,  as  the  reply.  After  she 
began  to  improve  she  rapidly  got  well,  having  been  previously  fattened 
with  milk  diet,  and  she  has  remained  quite  well  now  for  seven  years. 

This  was  a  case  with  cataleptic  symptoms. 

F.  Q.,  set.  27,  admitted  2d  April,  1881.  Disposition  bright  and 
cheerful.  Habits  steady  and  industrious.  First  attack.  No  hereditaiy 
predisposition.     Cause,  anxiety  in  regard  to  an  operation  for  removal  of 


STATES    OF    MENTAL    STUPOR.  227 

mammary  tumor  which  she  had  to  undergo.  Duration  about  five  weeks. 
Became  gradually  depressed,  lost  appetite,  fell  off  in  flesh,  slept  badly. 
Ultimately  became  quite  stupid,  was  unfit  for  her  work,  took  no  interest 
in  her  children,  would  stand  in  one  position  for  an  hour  or  two  continu- 
ously, and  was  very  restless  at  night. 

On  admission  she  was  in  a  state  of  stupor,  paying  no  attention  to 
questions  addressed  to  her  or  to  anything  occurring  near  her,  would  not 
utter  a  word,  stood  in  a  listless  and  stupid  attitude,  obeyed  no  orders, 
refused  food,  did  not  attend  to  the  calls  of  nature.  She  was  in  very 
poor  condition  and  weak  general  health.  She  was  unresistive,  cold,  and 
her  extremities  blue,  and  her  foce  expressed  vacancy,  not  melancholy. 

April  2>d. — Slept  well  for  some  hours,  but  was  restless  in  the  morning. 
Remains  in  a  state  of  stupor,  and  will  not  speak  a  single  word.  There 
is  a  distinct  degree  of  catalepsy.  Has  taken  plenty  of  food.  To  have 
custards,  plenty  of  extra  milk,  porter,  and  cod-liver  oil  emulsion,  and 
friction  to  skin,  with  extra  warm  clothing. 

April  ItJi. — Takes  her  food  readily  when  fed  with  it.  Still  very 
stupid.  Never  utters  a  single  word.  Will  not  employ  herself  in  any 
way.  Wanders  slowly  and  aimlessly  about  the  gallery  when  set  in  mo- 
tion.    When  allowed  to  do  so  will  sit  or  stand  any  length  of  time. 

April  10th. — General  health  rather  improved.  Yesterday  she  spoke 
a  few  sentences  to  the  attendants. 

April  15th. — Expression  of  face  more  intelligent.  Is  obstinately 
taciturn.     Sleeps  well. 

April  SOth. — Bodily  health  improving.     Mentally  little  change. 

Mai/  Slst. — Has  been  worse  since  last  note ;  stupor  more  pronounced ; 
cannot  be  got  to  speak,  or  to  work,  or  to  attend  to  herself;  wet  and  dirty 
in  her  habits. 

JVov.  1st. — Stupor  extreme.  Sits  constantly  in  one  position,  with 
head  bowed  down,  and  saliva  running  from  her  mouth.  Eyelids  are 
cedematous,  pulse  almost  imperceptible,  extremities  cold.  Ordered 
quiniae  sulph.  gr.  iv.,  tinct.  digitalis  ^i  xv.,  three  times  daily. 

JS^ov.  27th. — Has  been  confined  to  bed  for  some  days  lately,  owing  to 
the  extreme  general  weakness.  Mentally  there  is  some  improvement,  as 
she  brightens  up  slightly  at  times,  but  there  is  generally  profound  stupor. 

March,  1882. — There  is  still  pronounced  stupor,  but  its  character  is 
considerably  changed  ;  the  mental  faculties  seem  blunted  or  dead  ;  she  is 
utterly  careless  and  apathetic ;  she  is  slovenly  and  dirty,  requiring  to  be 
washed,  dressed,  and  attended  to  in  every  respect ;  she  never  volunteers 
a  remark,  and  indeed  never  utters  a  single  expression,  except  when  being 
bathed  or  dressed,  when  she  sometimes  gives  vent  to  expressions  of  dis- 
approbation and  disgust.  Her  expression  of  face  has  also  changed  of 
late.  Her  general  look  is  one  of  utter  stupidity  and  degradation,  the 
features  being  coarse  and  blurred,  the  saliva  dribbling  from  the  mouth ; 
but  frequently,  without  apparent  external  cause,  the  face  assumes  various 
exaggerated  expressions  of  disgust,  amusement,  and  eroticism,  while  at 
times  she  has  muflled  outbursts  of  chuckling  laughter.  She  takes  plenty 
of  food,  and  is  in  better  health  and  condition.  Muscularly  she  is  cata- 
leptic to  a  marked  degree. 


228  STATES    OF    MENTAL    STUPOR. 

In  the  next  twelve  months  she  improved  in  many  respects,  but  she 
then  died  of  diarrhoea. 

The  following  is  a  ease  of  anergic  stupor,  beginning  with  slight  melan- 
cholic symptoms,  and  caused  by  excessive  drinking : 

F.  R.,  aet.  40,  a  person  of  a  naturally  bad  and  untruthful  disposition, 
whose  exact  heredity  is  unknown.  She  is  the  daughter  of  a  Hindustani 
mother,  her  father  having  been  English.  Her  habits  were  always  indo- 
lent, but  of  late  they  have  been  very  drunken,  fickle,  and  degraded. 
Her  present  attack  began  by  melancholic  fears  that  persons  were  going 
to  kill  her,  restlessness,  incoherence,  and  screaming  at  night.  She  still 
drank,  and  has  become  more  and  more  confused  and  stupid.  On  admis- 
sion she  was  in  a  condition  of  stupor,  with  a  slight  melancholic  tinge. 
This  soon  passed  off,  and  her  stupor  became  complete  and  anergic  in 
character,  with  poor  circulation,  pulse  weak,  extremities  cold ;  urine  and 
feces  passed  as  she  lay  on  a  water  bed. 

Nothing  would  rouse  her  to  speak  or  take  any  notice  of  anything. 
For  about  a  year  this  condition  continued,  and  then  she  gradually  came 
out  of  it  in  a  partially  demented  condition,  with  uncleanly  habits,  erotic 
speech,  masturbation,  talking  and  laughing  to  herself,  delusions  of  iden- 
tity, inability  to  fix  her  attention  on  anything,  and  a  morbid  contentment 
with  her  position  in  the  asylum.  Thus  she  has  I'emained  for  four  years 
now,  and  thus  she  will  probably  remain  as  long  as  she  lives. 

The  following  is  a  complicated  case  of  stupor,  catalepsy  with  epilepti- 
form convulsions  ;  temporary  partial  recovery,  dementia : 

F.  S.,  8et.  17,  admitted  to  Royal  Edinburgh  Asylum,  2d  May,  1874. 
Disposition  quiet  and  dull ;  habits  steady  ;  family  history  not  ascertained ; 
assigned  cause  a  severe  blow  on  the  back  of  the  head  three  years  before 
admission,  since  which  he  has  been  duller  and  more  stupid.  The  injury 
seems  to  have  been  chiefly  spinal.  After  it  he  gradually  lost  complete 
control  over  the  movements  of  his  head  ("it  came  forward"),  then  he 
ceased  to  be  able  to  stretch  his  arms  forwards  and  back,  but  he  still  could 
write.  Was  sick,  and  sometimes  vomited.  Could  not  walk  far  or  run 
at  all  without  being  very  tired.  Had  pain  in  his  head.  About  three 
weeks  ago  showed  mental  symptoms,  viz.,  religious  anxiety,  delusions 
that  his  food  and  medicine  were  poisoned,  shouting,  violence,  and  dirty 
habits.  It  appears  that  an  epileptic  fit  immediately  preceded  those  symp- 
toms. Took  another  fit  sixteen  days  before  admission,  springing  right 
up  from  his  bed.  Convulsions  lasted  three-quarters  of  an  hour.  During 
the  fit  the  lip  and  tongue  were  bitten.  He  was  then  for  five  hours  in 
"a  trance."  His  head  had  been  shaved  and  blistered.  Had  six  or  seven 
fits  subsequent  to  this,  and  before  admission. 

On  admission  he  was  in  a  state  of  stupor,  with  no  mentalization  ap- 
parent, insensible  to  pain,  and  spinal  reflex  action  abolished.  Pulse  130, 
weak  ;  temperature  97.8°,  was  very  weak  ;  urine  and  feces  passed  in  bed. 

He  remained  in  this  stupor,  but  sometimes  cried  and  moaned,  and  took 
many  epileptifoim  fits  for  the  first  ten  days.  He  then  showed  the  true 
cataleptic  symptoms,  his  body  assuming  any  position  it  was  placed  in  for 
any  length  of  time.  He  took  no  notice  of  anything,  and  would  not 
answer  questions.  One  night  the  attendant  got  him  up,  put  the  chamber- 
pot in  his  hands  under  his  penis,  went  away,  and  forgot  all  about  it,  and 


STATES    OF    MENTAL    STUPOR.  229 

he  was  found  in  the  same  position  in  the  middle  of  the  night  by  the  night 
attendant.  He  remained  cataleptic  and  unconscious  for  eight  days,  when 
he  had  a  feverish  attack  with  diarrhoea,  temperature  being  103°.  While 
this  lasted,  he  could  be  roused  to  answer  questions  in  monosyllables,  and 
appeared  to  be  more  conscious  and  intelligent.  After  the  fever  subsided 
he  again  became  completely  cataleptic.  There  collected  and  ran  out  of 
his  mouth  a  fetid  greenish  fluid  somewhat  purulent  in  character.  Some- 
times he  had  to  be  fed  with  the  stomach-pump.  The  food  always  had  to 
be  made  liquid.  During  all  the  time,  up  till  August  10th,  he  had  mus- 
cular twitchings  of  the  extremities,  and  occasionally  a  regular  epileptic 
fit.     Pulse  then  60,  weak  and  irregular;  temperature  98.9°. 

During  September  he  began  to  move  slowly  by  volition  in  a  snail-like 
way,  without  speech  or  expression  in  his  face.  W  hen  up,  and  told 
sharply  to  get  into  bed,  he  would  move  slowly  and  manage  to  get  there 
in  half  an  hour  or  so.  Bowels  very  costive.  When  much  roused,  on 
September  17th,  he  got  up  and  walked  along  the  corridor.  There  were 
no  fits  after  the  18tli  of  September.  He  steadily  improved  after  this, 
still  being  slow  and  stupid,  affectively  religious,  going  to  church,  and 
saying  very  long  prayers  before  going  to  bed.  In  October  he  was  able 
to  dress,  undress,  go  out  to  do  a  little  garden  work,  but  stolid,  slightly 
enfeebled  in  mind,  reserved,  wanting  in  curiosity  and  interest,  and  as  if 
he  had  some  latent  morbid  fancies. 

On  November  8,  1875,  he  Avas  discharged  as  "recovered,"  being  co- 
herent and  intelligent,  but  there  was  present  some  of  the  general  listless 
mental  state  referred  to. 

He  did  very  well  at  home  for  a  time,  but  a  process  of  gradual  mental 
enfeeblement  seems  to  have  come  on,  with  irascibility  and  sometimes 
violence,  so  that,  on  4th  of  June,  1878,  he  was  readmitted  to  the  asylum 
in  a  state  of  ordinary  sequential  dementia.  He  still  remains  there.  He 
has  never  had  any  recurrence  of  the  epileptiform  fits. 

There  are  two  additional  facts  which  one  may  assume,  though  they  do 
not  appear  in  this  record.  The  first  is  that  there  must  have  been  a 
strong  heredity  to  insanity.  The  second  is  that  the  lad  practised  mas- 
turbation to  excess. 

He  says  he  has  no  recollection  of  what  occurred  during  his  period  of 
stupor.  That  I  believe.  I  look  on  such  a  case  as  being  partly  caused 
by  adolescence,  complicated  by  masturbation  and  traumatism,  all  of  which 
were  concerned  in  the  causation  of  the  epileptic  attacks  and  the  condition 
of  stupor. 

Secondary  Stupor. — All  acute  forms  of  mental  disease  are  liable  to 
be  followed,  after  the  acute  symptoms  have  passed  oif,  by  a  condition  of 
mental  torpor  and  a  kind  of  mental  enfeeblement.  But  this  difiers  es- 
sentially from  the  true  secondary  dementia.  There  is  in  it  to  a  large 
extent  the  mental  characters  which  I  have  described  as  being  those  of 
stupor,  and  above  all  it  is  curable.  The  patients  are  inattentive,  con- 
fused, lethai'gic,  and  torpid.  The  brain  reflexes  are  dulled.  The  ener- 
gizing of  the  convolutions  is  slow  and  confused.  All  the  higher  reason- 
ing and  aflective  powers  are  in  abeyance  for  the  time  being.  It  is  a  time 
of  exceeding  importance  for  treatment,  which  should  be  supporting,  tonic, 


230  STATES    OF    MENTAL    STUPOR. 

nutritive,  and  not  exciting ;  though  nerve  stimulants  and  counter-irrita- 
tion to  the  head  are  often  of  service. 

General  Paralytic  and  Epileptic  Stupor. — The  condition  of 
stupor  of  the  anergic  kind  is  often  an  incident  in  those  two  diseases,  most 
frequently  following  attacks  of  convulsions  or  congestive  attacks,  but 
sometimes  coming  on  of  itself  without  any  reference  to  such  motor  symp- 
toms. Wherever  there  has  been  prolonged  stupor  in  general  paralysis, 
we  find  much  brain  atrophy  after  death. 

Causation. — The  causes  of  stupor  are  the  following: 

1.  Sexual.  The  chief  of  these  is  the  habit  of  masturbation.  I  have 
met  with  it  also  as  a  post-connubial  condition,  or  from  excessive  sexual 
intercourse  in  both  sexes  in  adolescents.  In  some  cases  it  seemed  as  if 
the  mental  and  emotional  exaltation  had  acted  as  strongly  as  the  physical 
exhaustion.     F.  P.,  and  F.  S.  were  examples. 

2.  Mental  and  moral  shocks  and  over-work  during  adolescence. 

3.  The  brain  exhaustion  caused  by  acute  mental  diseases,  more  especi- 
ally acute  mania. 

4.  Stupor  often  occurs  as  an  incident  or  stage  in  other  mental  diseases, 
notably,  as  we  have  seen,  in  general  paralysis  and  epilepsy. 

5.  An  alcoholic  stupor  may  be  caused  by  excessive  drinking,  and  is 
thus  one  form  of  alcoholic  insanity.  Such  a  condition  is  usually  transi- 
tory, but  not  always. 

6.  Stupor  is  frequently  one  of  the  stages  of  alternating  insanity  fol- 
lowing the  exalted  condition.  It  is  more  apt  to  occur  in  those  where  the 
exalted  period  is  acutely  maniacal.  This  stupor  is  usually  the  melan- 
cholic form.  The  older  the  patient  the  more  apt  is  the  stage  of  reaction 
after  exaltation  to  be  one  of  stupor.  I  have  now  under  my  care  an  old 
gentleman  of  eighty -four,  who,  when  his  periods  of  exaltation  are  unusually 
long,  will  afterwards  become  torpid,  never  speak  or  take  any  notice  of 
anything,  will  not  even  stand,  but  must  be  kept  in  bed,  will  scarcely 
swallow,  and  this  will  sometimes  continue  for  four  or  five  weeks.  When 
younger,  he  never  had  such  attacks.  He  has  labored  under  irregularly 
alternating  insanity  for  thirty  years. 

7.  Senility.  In  the  extreme  form  of  senile  insanity,  the  mental  facul- 
ties disappear  so  entirely  as  to  constitute  them  cases  of  stupor. 

Some  of  these  causes  may,  of  course,  coexist.  The  sexual  and  alco- 
holic are  very  apt  to  do  so. 

Prognosis  in  Stupor. — In  its  typical  form,  in  young  persons  of  both 
sexes,  the  anergic  form  (acute  dementia)  is  a  very  curable  form  of  mental 
disease.  The  melancholic  form  is  not  so  curable,  but  about  fifty  per  cent, 
of  the  cases  recover. 

Treatment  of  Stupor. — All  forms  need  much  the  same  treatment, 
but  in  the  anergic  cases  it  needs  to  be  supporting  and  stimulating,  and 
in  the  melancholic  more  supporting  at  first,  and  stimulating  afterwards. 
Quinine,  iron,  strychnine  pushed  to  large  doses,  ergot,  warmth,  the  con- 
tinued current,  exercise,  friction,  alcoholic  stimulants,  rousing  moral 
treatment,  occupation,  distraction  of  mind  are  the  general  indications. 
In  the  relation  of  the  clinical  histories  of  the  cases  described  the  treat- 
ment has  been  sufiiciently  spoken  of. 


LECTURE    IX. 

STATES  OF  DEFECTIVE  INHIBITION  {PSYCHO-KINESIA ;  HYPER- 
KINESIA ;  INHIBITORY  INSANITY;  IMPULSIVE  INSANITY;  INSANE 
IMPULSE;  VOLITIONAL  INSANITY;  UNCONTROLLABLE  IMPULSE; 
INSANITY  WITHOUT  DELUSIONS,  EXALTATION,  DEPRESSION, 
OR  ENFEEBLEMENT ;  AFFECTIVE  INSANITY). 

THE   INSANE    DIATHESIS. 

The  want  of  the  power  of  self-control  is  so  very  common  a  thing 
amongst  mankind,  that  to  some  extent,  and  in  respect  to  some  matters,  it 
may  be  regarded  as  the  normal  condition  of  our  species.  A  perfect 
capacity  of  self-control  in  all  directions  and  at  all  times  is  rather  the  ideal 
state  at  which  we  aim  than  the  real  condition  of  any  of  us.  The  men 
who  have  attained  this  state  of  inhibitory  perfection  have  been  few  and 
far  between,  and  even  in  regard  to  them  it  may  be  said  that  they  too 
would  have  lost  their  self-control  if  they  had  been  exposed  to  sufficient 
temptation  or  irritation.  But  while  a  perfect  mental  inhibition  may  not 
be  attainable,  there  is  a  certain  amount  of  this  power  in  all  directions, 
and  an  absolute  power  in  some  directions  that  is  expected  of  all  sane 
persons.  All  sane  men  must  control  to  some  extent  their  animal  desires, 
and  they  must  control  absolutely  any  desires  they  may  have  towards 
homicide.  The  law  assumes,  as  the  basis  of  all  its  enactments,  that  all 
men  have  the  inherent  power  to  do  certain  things  and  avoid  other  things 
that  would  be  inconsistent  with  the  well-being  of  society,  or  the  safety  or 
comfort  of  their  fellow-men.  If  a  man  is  born  of  criminal  parents,  and 
has  been  taught  to  prey  on  his  fellows,  and  look  on  them  as  having  no 
rights  that  he  is  bound  to  respect,  if  from  no  fault  of  his  own  his  brain 
is  weak,  and  no  sense  of  right  and  wrong  has  been  implanted  in  him  at 
all,  yet  in  spite  of  all  this  he  is  held  as  fully  responsible  by  the  law  as 
the  strongest,  best  taught,  and  most  favorably  circumstanced  man  in  the 
country;  and  this  is  at  present  unavoidable,  however  unscientific  it  is 
from  the  physiological  and  psychological  aspect  of  brain  and  mind  ftmc- 
tion.  Laws  are,  after  all,  largely  the  reflexes  of  the  laws  of  nature.  If 
a  man  has  not  been  taught  that  an  excessive  use  of  alcohol  damages  or 
kills,  and  he  drinks  it  to  excess,  he  suffers  just  as  much  as  the  man  who 
knows  its  bad  effects,  and  deliberately  poisons  himself  with  it.  But  to 
this  assumed  power  of  mental  control  in  all  men  the  laAV  makes  certain 
exceptions.  The  first  of  these  is  in  regard  to  children,  and  the  second  is 
in  regard  to  persons  whose  mental  power  has  been  affected  by  disease  or 
want  of  brain  development. 

The  subject  of  mental  inhibitory  power  should  first  be  studied  by  us 
medical  men  from  the  point  of  view  of  its  gradual  development  in  chil- 
dren.   Take  a  child  of  six  months,  and  there  is  absolutely  no  such  brain 


232  STATES    OF    DEFECTIVE    INHIBITION. 

power  existent  as  mental  inhibition;  no  desire  or  tendency  is  stopped  or 
controlled  by  a  mental  act.  At  a  year  old  the  rudiments  of  the  great 
faculty  of  self-control  are  clearly  apparent  in  most  children.  They  will 
resist  the  desire  to  seize  the  gas  flame,  they  Avill  not  upset  the  milk  jug, 
they  will  obey  orders  to  sit  still  when  they  want  to  run  about,  all  through 
a  higher  mental  inhibition.  But  the  power  of  control  is  just  as  gradual  a 
development  as  the  motions  of  the  hands.  There  is  no  day  or  year  in 
a  child's  life  after  which  killing  its  little  brother  is  murder,  and  before 
which  it  was  no  crime  at  all.  The  law  admits  and  provides  in  a  rough 
way  for  this  physiological  fact  as  to  self-control.  We  physicians  see  that 
this  faculty  is  developed  at  dift*erent  ages  in  different  cases.  We  are 
bound  to  give  credence  to  all  physiological  facts  and  laws,  and  it  is  as 
much  a  fact  that  different  brains  have  different  degrees  of  controlling 
power  after  their  full  development,  as  it  is  that  they  attain  their  power  of 
control  at  different  ages.  As  we  watch  children  grow  up,  we  see  that 
some  have  the  sense  of  right  and  wrong,  the  conscience,  developed  much 
sooner  and  much  stronger  than  others,  just  as  some  have  their  eye-teeth 
much  sooner  than  others;  and,  looking  at  adults,  we  see  that  some  never 
have  much  of  this  sense  developed  at  all.  This  is  notoriously  the  case 
in  those  whose  ancestors  for  several  generations  have  been  criminals, 
insane,  or  drunkards.  Then,  again,  in  other  persons  the  sense  of  right 
and  wrong  is  painfully  keen  from  early  childhood,  and  the  desire  to  follow 
the  one  and  avoid  the  other  earnestly  striven  after  from  the  first.  In 
some,  therefore,  conscience  is  anaesthetic,  in  others  hypergesthetic,  just  as 
sensation  may  be.  Notoriously  it  is  a  bad  thing  to  force  any  sense  or 
mental  faculty  into  too  great  activity  till  its  brain  substratum  is  sufficiently 
developed.  I  have  known  many  children  whose  anxious  parents  had 
made  them  morally  hypersesthetic  at  early  ages  through  an  ethical  forcing- 
house  treatment.  I  knew  one  little  boy  of  four,  Avho,  by  dint  of  con- 
stant effort  on  the  part  of  his  mother,  was  so  sensitive  as  to  right  and 
wrong  that  he  never  ate  an  apple  without  first  considering  the  ethics  of 
the  questions  as  to  whether  he  should  eat  it  or  not;  who  would  suffer 
acute  misery,  cry  most  bitterly,  and  lose  some  of  his  sleep  at  night  if  he 
had  shouted  too  loud  at  play,  or  taken  more  than  his  share  of  the  cake, 
he  having  been  taught  that  these  things  were  "wrong"  and  "displeasing 
to  God."  But  the  usual  anaesthesia  that  follows  too  keen  feeling  succeeded 
to  the  precocious  moral  intensity  in  this  child,  for  at  ten  he  was  the  greatest 
imp  I  ever  saw,  and  could  not  be  made  to  see  that  smashing  his  mother's 
watch,  or  throwing  a  cat  out  of  the  window,  or  taking  what  was  not  his 
own,  were  wrong  at  all.  We  know  that  some  of  the  children  of  many 
generations  of  thieves  take  to  stealing  as  a  young  wild  duck  among  tame 
ones  takes  to  hiding  in  holes,  and  that  the  children  of  savage  races  can- 
not be  taught  at  once  our  ethical  feelings.  It  seems  to  take  many  gen- 
erations to  redevelop  an  atrophied  conscience.  Professor  Benedick,  of 
Vienna,  showed,  at  the  International  Medical  Congress  of  1881,  in 
London,  a  number  of  brains  of  habitual  criminals  which  he  affirmed  had 
their  convolutions  arranged  in  a  certain  simple  form  peculiar  to  the 
criminal  classes,  so  that  on  seeing  such  a  brain  he  could  tell  the  ethical 
tendencies  of  the  person  to  whom  it  belonged,  just  as  you  can  tell  a  dog 
to  be  a  bull-dog  by  his  jaws.    There  is  no  doubt  that  an  organic  lawless- 


STATES    OF    DEFECTIVE    INHIBITION.  233 

ness  is  transmitted  hereditarily.  Among  the  many  transmitted  morbid 
peculiarities  in  the  children  of  neurotic  and  insane  parents  this  is  often 
one.  Either  a  too  morbid  intensity  of  desire,  or  a  morbid  weakness  of 
control,  renders  such  children  prone  to  early  morbid  immoralities. 

In  the  delirium  of  fevers  and  the  ravings  of  the  acuter  forms  of  in- 
sanity, no  form  of  self-control  is  expected.  The  law,  from  the  earliest 
times,  entirely  exempted  persons  suffering  from  such  conditions  from 
responsibility  for  acts  done  under  their  influence.  A  study  of  the  dif- 
ferent varieties  of  insanity  shows  us  that  the  power  of  self-control  differs 
enormously  in  the  various  forms,  and  in  different  individuals  laboring 
under  the  same  form,  while  there  is  no  line  of  demarcation  between  the 
state  in  which  a  man  has  "perfect  self-control "  (to  use  an  expression  that 
cannot  be  literally  true  in  any  case)  and  that  in  which  he  has  none  at 
all.  Self-control,  in  short,  like  all  physiological  qualities  and  all  mental 
faculties,  exists  in  every  possible  degree  of  strength.  Sufficient  power 
of  self-control  should  be  the  essence  and  legal  test  of  sanity,  if  we  had 
any  means  of  estimating  it  accurately.  The  accurate  clinical  study  of 
mind  in  relation  to  its  ordinary  physiological  accompaniments,  in  health 
and  disease,  will,  I  believe,  help  us  in  time  to  make  such  an  estimate  in 
any  particular  case  far  more  accurately  than  we  are  now  able  to  do. 
The  practising  physician,  from  his  daily  acquaintance  with  the  physio- 
logical facts  of  nature,  instinctively  makes  allowances  for  lack  of  self- 
control  in  his  patients  when  they  are  ill,  apart  from  technical  insanity. 
He  knows  that  the  thing  called  "irritability"  merely  means  lack  of  full 
vital  poAver,  that  the  "impulses"  of  the  hysterical  girl  are  simply  mor- 
bidly transformed  modes  of  energy  temporarily  bursting  the  bounds  of  the 
patient's  will,  just  as  fits  of  weeping  are  often  involuntary  and  uncon- 
trollable. But  the  lawyer,  and  the  medical  man,  who,  as  a  medico-legal 
witness  or  adviser,  has  to  consider  the  social  and  legal  aspect  and  effect 
of  his  opinions,  are  still  chary  of  admitting  mere  loss  of  control  or  morbid 
impulse  as  an  excuse  for  crime.  They  both  like  to  have  other  evidence 
of  disorder  of  the  mental  function,  in  the  shape  of  insane  delusion  or 
incoherence  of  speech,  before  they  are  willing  to  put  forward  the  plea  of 
diseased  want  of  self-control  in  mitigation  of  legal  punishment.  Another 
element  than  medical  facts  comes  in  then,  viz.,  the  practical  effect  of  their 
opinions  on  society.  In  a  community  of  perfectly  law-abiding  people  a 
murder  would  naturally  be  attributed  to  disease,  and  no  objection  would 
be  taken  by  any  one  to  that  view  of  it.  But  with  the  world  as  it  exists, 
it  is  different. 

Before  we  can  give  any  opinion  as  to  the  responsibility  or  irresponsi- 
bility of  any  case  in  a  court  of  law,  we  should  see  as  many  cases  as  we 
can  where  want  of  controlling  power  or  impulsive  tendencies  constitute 
the  disease  or  the  chief  part  of  it.  Such  cases  exist,  though  they  are  not, 
in  a  pure  form,  very  numerous.  As  one  stage  in  cases  of  insanity  they 
are  frequent.  Half  the  suicidal  melancholies  at  the  beginning  dread  the 
moment  when  their  self-control  will  be  lost.  Many  of  the  maniacal  cases 
show  at  an  early  stage  only  loss  of  self-control,  before  motor  excitement 
or  incoherence  comes  on.  If  one  has  seen  many  persons  in  this  state 
about  whom  there  could  be  no  doubt  as  to  their  disease,  and  if  one  has 
systematically  studied  the  loss  of  self-control  or  morbid  impulse  as  a 


234  STATES    OF    DEFECTIVE    INHIBITION. 

mental  symptom  in  the  various  forms  it  is  found  to  assume,  sucli  experi- 
ence and  study  bring  much  confidence  to  us  in  giving  private  medical 
advice  about  this  matter,  or  in  giving  evidence  in  the  witness-box  in 
regard  to  one  of  the  most  responsible  and  difficult  questions  about  which 
a  medical  man  has  to  come  to  a  decision. 

Consider  first  the  variety  of  simple  motor  impulses  or  acts  that  are 
physiologically  uncontrollable,  or  partly  so,  such  as  coughing,  vomit- 
ing, etc.  Next,  look  at  a  more  complicated  act,  that  will  be  recognized 
by  any  competent  physiologist  to  be  automatic  and  beyond  the  control  of 
any  ordinary  inhibitory  power,  e.  g.,  irritate  and  tease  a  young  child  of 
one  or  two  years  sufiiciently,  and  it  will  strike  out  at  you ;  suddenly  strike 
at  a  man,  and  he  will  either  perfonn  an  act  of  defence  or  offence,  or  both, 
quite  automatically,  and  without  power  of  controlling  himself.  Place  a 
bright  tempting  toy  before  a  child  of  a  year  and  it  will  be  instantly 
appropriated.  Place  cold  water  suddenly  before  a  sane  man  dying  of 
thirst,  and  he  will  take  and  drink  it  without  power  of  doing  otherwise. 
Exhaustion  of  nervous  energy  always  lessens  the  inhibitory  power.  AVho 
is  not  conscious  of  this?  "Irritability"  is  one  manifestation  of  this. 
Many  persons  have  so  small  a  stock  of  reserve  brain  power — that  most 
valuable  of  all  brain  qualities — that  it  is  soon  used  up,  and  you  see  at 
once  that  they  lose  their  power  of  self-control  very  soon.  They  are 
angels  or  demons,  just  as  they  are  fresh  or  tired.  That  surplus  store  of 
energy  or  resistive  force  which  provides  in  persons  normally  constituted 
that  moderate  excesses  in  all  directions  shall  do  no  great  haim,  so  long 
as  they  are  not  too  often  repeated,  not  being  present  in  those  people, 
over-work,  over-drinking,  or  small  debauches,  leave  them  at  the  mercy  of 
their  morbid  impulses  without  poAver  of  resistance.  Some  persons  of 
more  mental  and  nerve  force  have  the  fatal  power  of  keeping  themselves 
at  work  or  at  dissipation  till  this  surplus  reserve  stock  of  resistiveness  is 
altogether  exhausted,  and  they  then  become  unresistive  against  morbid 
impulses.  Woe  to  the  man  who  uses  up  his  surplus  stock  of  brain  inhi- 
bition too  near  the  bitter  end,  or  too  often ! 

In  relation  to  the  medico-psychological  problems  of  mental  inhibition 
and  impulse,  we  have  to  take  into  account  those  obscure  human  ten- 
dencies towards  killing,  towards  destructiveness,  towards  appropriation, 
towards  unrule,  some  of  which  exist  as  inchoate  physiological  tendencies 
more  or  less  strong  in  most  human  beings,  and  the  gratifying  of  which 
gives  pleasure.  They  are  best  seen  in  youth,  and  they  often  come  out  in 
a  strong  way  in  disease.  Be  they  transmitted  qualities  of  our  far-ofi" 
progenitors,  or  physiological  weapons  to  help  us  in  the  struggle  for  exist- 
ence, or  other  and  normal  physiological  energies  transmuted,  there  they 
are,  and  we  must  accept  them  as  facts  of  nature. 

The  doctrine  of  nervous  inhibition  and  of  inhibitory  centres  has  done 
very  much  to  definitize  our  notions  in  regard  to  the  mental  working  of 
the  brain.  There  is,  of  course,  no  proof  of  mental  inhibitory  centres, 
but  there  is  mental  inhibition,  and  a  function  always  implies  an  organ  of 
some  sort.  When  it  was  demonstrated  that  the  excitation  of  certain 
nerves  caused  not  motion,  but  stoppage  of  motion ;  when  it  was  proved 
that  the  nutrition  of  the  tissues  was  largely  influenced  by  the  increased 
or  diminished  potency  of  the  capillaries  or  arterioles,  and  that  the  latter 


STATES    OF    DEFECTIVE    INHIBITION.  235 

was  dependent  on  two  sets  of  nerves  and  two  sets  of  centres,  one  to  open 
and  the  other  to  shut  those  vessels,  such  physiological  facts  were  at  once 
correlated  with  the  facts  observed  in  conditions  of  mental  excitation  and 
depression,  mental  quickening  and  slowing,  emotional  supersensitiveness 
and  torpor,  and  the  conclusion  Avas  arrived  at  that  in  the  higher  depart- 
ment there  must  be  a  somewhat  similar  apparatus  for  regulating  the 
exercise  of  the  mental  functions  of  the  brain,  and  that  disorders  of  these 
would  probably  make  all  the  difference  between  sanity  and  insanity, 
between  self-control  and  insane  impulse.  That  there  was  a  physiological 
analogy  between  the  jactitation  of  the  limbs  of  a  man  with  chorea,  who 
tries  to  control  these  motions,  but  is  not  able  to  do  so,  and  the  insane 
impulse  to  murder  and  violence  which  the  patients  are  aware  of,  deplore, 
and  fruitlessly  try  to  resist,  but  are  totally  unable  to  do  so,  seemed  very 
evident.  In  the  one  case,  a  controlling  centre  or  centres  of  motion  are 
not  doing  their  work,  either  from  absolute  loss  of  their  own  internal 
power  of  governance,  or  from  an  excess  of  energy  generated  in  the  lower 
motor  centres  of  the  choreic  limbs;  in  the  other,  the  controlling  centres 
of  mentalization  and  feeling  are  not  doing  their  work  for  the  same  reasons. 
We  know  that  there  are  controlling  centres  of  even  many  of  the  lower 
reflex  functions,  and  there  can  be  no  doubt  that  they  exist  also  to  control 
the  great  reflex  functions  of  the  cerebrum,  which  were  so  clearly  ex- 
pounded by  Laycock.  That  doctrine  has  done  much  to  make  us  under- 
stand better  the  mental  functions  of  the  brain  and  their  derangements. 
Let  us  glance  at  an  example.  The  maternal  instinct  of  cai'e  and  affection 
for  offspring  is  a  mental  function  of  brain  common  to  man  with  the  lower 
animals,  and  ranks  next  to  the  love  of  life  and  the  desire  to  reproduce  the 
species  in  importance,  while  it  surpasses  these  in  conscious  intensity  for 
the  time  it  is  in  operation.  Its  periods  of  activity  are,  of  course,  inti- 
mately connected  with  the  activity  of  the  reproductive  organs.  The 
objects  of  the  instinct  need  not  necessarily  be  the  animal's  own  offspring. 
Cats  will  suckle  and  take  tender  care  of  young  rabbits  when  their  maternal 
instinct  is  in  full  activity  after  parturition  and  when  the  mammge  are 
functionally  active.  There  is  a  nervous  influence  sent  up  from  these 
organs  to  some  portion  of  the  brain,  rousing  it  into  activity,  and  so 
developing  the  feeling  for  young,  and  the  unceasing  innumerable  acts  of 
care,  defence,  playing  with,  and  protection,  which  for  the  time  dominate 
the  whole  mental  life  and  outward  actions  of  the  animal.  Artificial  irri- 
tation of  the  mammse  without  previous  parturition  will  sometimes  develop 
this  instinct.  In  the  case  of  the  cat  suckling  the  young  rabbits,  it 
entirely  inhibited  the  opposite  instinct  to  kill  and  eat  them.  In  condi- 
tions of  disease,  the  maternal  instinct  is  completely  perverted  in  its 
exercise,  so  that  animals  sometimes  eat  and  destroy  their  young.  Now, 
the  same  thing  happens  in  the  human  species.  In  the  insanity  which 
occurs  after  childbirth  one  of  the  most  common  symptoms  is  either  an 
entire  inhibition  of  the  maternal  instinct,  so  that  "a  woman  forgets  hei' 
suckling  child,"  or  an  entire  perversion  of  it,  so  that  she  wants  to  destroy 
her  own  offspring. 

The  physiological  word  inhibition  can,  therefore,  be  used  synonymously 
with  the  psychological  and  ethical  expression  self-control,  or  with  the  will 
when  exercised  in  certain  directions.     It  is  the  characteristic  of  most 


236  STATES    OF    DEFECTIVE    INHIBITION. 

forms  of  mental  disease  for  self-control  to  be  lost,  but  this  loss  is  usually 
part  of  a  general  mental  affection  with  melancholic,  maniacal,  demented, 
or  delusional  symptoms  as  the  chief  manifestations  of  the  disease.  There 
are  other  cases,  not  so  numerous,  where  the  loss  of  the  power  of  inhibi- 
tion is  the  chief  and  by  far  the  most  marked  symptom.  Those  we  are 
now  to  consider  and  study.  I  shall  call  this  form  "Inhibitory  Insanity." 
Some  of  these  cases  have  uncontrollable  impulses  to  violence  and  destruc- 
tion, others  to  homicide,  others  to  suicide  prompted  by  no  depressed 
feelings,  others  to  acts  of  animal  gratification  (satyriasis,  nymphomania, 
erotomania,  bestialit}^),  others  to  drinking  too  much  alcohol  (dipsomania), 
others  towards  setting  things  on  fire  (pyromania),  others  to  stealing 
(kleptomania),  and  others  towards  immoralities  of  all  sorts  (moral  in- 
sanity). The  impulsive  tendencies  and  morbid  desires  are  innumerable 
in  kind.  Many  of  these  varieties  of  insanity  have  been  distinguished  by 
distinct  names.  To  dig  up  and  eat  dead  bodies  (necrophilism),  to  wander 
from  home  and  throw  off  the  restraints  of  society  (planomania),  to  act 
like  a  wild  beast  (lycanthropia),  etc.  Action  from  impulse  in  all  these 
directions  may  take  place  from  a  loss  of  controlling  power  in  the  higher 
regions  of  the  brain,  or  from  an  over-development  of  energy  in  certain 
portions  of  the  brain,  which  the  normal  power  of  inhibition  cannot  con- 
trol. The  driver  may  be  so  weak  that  he  cannot  control  well-broken 
horses,  or  the  horses  may  be  so  hard-mouthed  that  no  driver  can  pull 
them  up.  Both  conditions  may  arise  from  purely  cerebral  disorder,  or 
from  cerebral  excitation  or  paralysis  caused  by  eccentric  agency  in  the 
organs — it  may  be  reflex,  in  short.  The  former  of  these  may  be  without 
consciousness  at  all,  the  ego,  the  will,  the  man  being  non-existent  for  the 
time.  The  most  perfect  examples  of  this  are  murders  done  during  som- 
nambulism or  epileptic  unconsciousness,  or  acts  done  in  the  hypnotic 
state.  There  is  no  conscious  desire  to  attain  the  object  at  all  in  such 
cases.  In  other  cases  there  are  consciousness  and  memory  present,  but  no 
power  of  restraining  action.  The  simplest  example  of  this  is  where  an 
imbecile  or  a  dement,  seeing  something  glittering,  appropriates  it  to  him- 
self, or  when  he  commits  indecent  sexual  acts.  Through  disease  a  pre- 
viously sane  and  vigorous-minded  person  may  get  into  the  same  state. 
The  motives  that  would  lead  other  persons  not  to  do  such  acts  do  not 
operate  in  such  persons.  I  have  known  a  man  steal  who  said  he  had  no 
intense  longing  for  the  article  he  appropriated  at  all,  at  least  consciously, 
but  his  will  was  in  abeyance,  and  he  could  not  resist  the  ordinary  desire  of 
possession  common  to  all  human  nature.  I  have  known  a  married  man 
indulge  in  masturbation  in  the  same  way.  He  knew  it  was  wrong,  and 
he  had  opportunity  of  sexual  intercourse,  but  he  could  not  resist  this 
simple  and  unnatural  mode  of  sexual  excitation.  Volition  and  resistive 
power  were  paralyzed. 

The  second  class  of  impulsive  acts,  where  we  seem  to  have  normal 
volitional  power,  but  the  impulses  so  morbid  and  so  strong  that  they  can- 
not be  resisted,  is  often  seen  by  the  physician  in  the  early  stages  of  mental 
disease  before  its  symptoms  have  fully  developed.  Its  existence  may  be 
called  in  question  by  a  priori  sociologists,  may  be  ridiculed  by  journalists, 
and  the  dangers  of  admitting  its  existence  may  be  painted  in  dark  colors 
by  lawyers,  but  that  it  exists  as  a  fact  in  the  history  of  human  nature  no 


STATES    OF    DEFECTIVE    INHIBITION.  237 

one  can  doubt  who  has  actually  seen  the  terror  and  agony  of  a  mother 
conscious  of  an  impulse  to  destroy  her  child,  and  striving  against  it  with 
vehement  resolution.  A  lady  came  to  me  lately  to  consult  me,  and  this 
was  part  of  her  conversation :  "  Thoughts  of  putting  myself  away  come 
suddenly  into  my  mind  when  I  am  working  and  quite  cheerful.  Oh ! 
my  God  I  if  I  could  get  these  thoughts  out  of  my  head,  Avhat  would  I 
not  give?  I  could  and  do  scream  for  relief  sometimes.  Oh,  me!  it's 
horrible  I  It  comes  on  me  that  some  day  I  will  take  away  my  life  or 
that  of  my  children.  I  had  this  idea  before  I  was  married  at  times. 
My  mother  had  it.  It  comes  on  me  in  one  instant,  and  some  day  I  will 
not  be  able  to  resist  it.  It  seems  now  as  if  there  was  a  galvanic  battery 
up  from  your  floor  up  to  my  brain  that  makes  my  head  feel  queer  and 
tingling.  Filthy  words  and  bad  thoughts  shoot  into  my  mind  too  in  the 
same  way."  And  she  thrcAv  herself  on  her  knees  in  an  agony  of  dis- 
tress, beseeching  God  and  me  to  deliver  her  from  these  homicidal  and 
suicidal  impulses.  Yet  a  minute  before  she  had  been  cheerful  and  laugh- 
ing, and  a  few  minutes  after  she  was  the  same.  No  doubt  the  theory  of 
uncontrollable  impulse  is  liable  to  abuse,  and  to  be  applied  Avhere  it  does 
not  exist ;  but  one  might  as  well  assume  that  there  is  no  real  epilepsy 
because  malingerers  and  hysterical  girls  simulate  fits,  or  that  there  is  no 
such  condition  as  hypnotism  because  rogues,  fools,  and  quacks  dabble  in 
deceit  and  call  it  mesmerism. 

The  states  of  defective  inhibition  and  impulse  may  be  momentary  in 
duration,  or  may  be  constant.  They  may  be  slight  in  form,  or  most  in- 
tense. Their  etiology  is  varied.  As  a  general  rule  they  are  met  with 
either  in  those  hereditarily  predisposed  to  the  neuroses,  or  in  those  whose 
normal  brain-functions  have  been  impaired  by  over-indulgence  in  alcohol 
or  nervous  stimuli  on  the  part  of  themselves  or  their  parents.  In  some 
few  cases  a  merely  defective  training  of  the  brain  in  youth  seems  to  end 
in  morbid  hyperkinesia.  No  doubt,  if  we  could  devise  a  perfect  mode  of 
teaching  self-control  to  the  young  brain  it  would  be  an  educational  dis- 
covery the  most  valuable  yet  made  by  humanity.  The  great  crises  of  life 
sometimes  set  up  this  condition — puberty,  adolescence,  the  climacteric 
period,  senility.  In  many  cases  there  have  been  congenital  or  early  de- 
fects of  brain  development,  causing  volitional  and  moral  imbecility,  or 
what  Morel  called  instinctive  juvenile  mania.  Visceral  derangements 
and  reflex  irritations  are  the  causes  in  many  cases.  Who  does  not  feel 
his  volition  or  control  sympathize  with  the  state  of  his  digestion.  I 
knew  a  young  woman  who,  during  menstruation,  which  was  with  her 
difficult  and  painful,  did  all  sorts  of  impulsive  acts — eat  dirt,  hurt  herself, 
and  pinch  children — while  she  was  at  other  times  amiable,  and  did  none 
of  these  things.  There  is  no  doubt  that  the  organic  instinct  of  repro- 
duction becomes  transmitted  morbidly  into  instinctive  impulses  to  kill, 
steal,  etc. 

I  shall  confine  my  observations  to  the  commoner  and  more  typical 
varieties  of  morbid  impulse,  and  they  are  the  following:  a.  general 
psychokinesia ;  h.  epileptiform  impulse ;  c.  animal  and  organic  impulse ; 
d.  homicidal  impulse ;  e.  suicidal  impulse ;  /.  destructive  impulse ;  g. 
dipsomania  ;  li.  kleptomania  ;  j.  pyromania  ;  k.  moral  insanity. 


238  STATES    OF    DEFECTIVE    INHIBITION. 

General  psycliokinesia  or  impulsiveness  in  all  directions  is  well  illus- 
trated in  the  following  case,  who  was  a  patient  of  mine  in  Morningside : 

E.  L.,  set.  47,  of  a  very  neurotic  heredity,  a  brother  being  epileptic, 
and  her  sisters  very  nervous  women.  In  addition  to  this,  she  has  had 
twenty  years  of  sorrow  and  domestic  worry,  with  a  drunken  husband 
who  could  not  provide  for  her,  and  through  the  loss  of  several  of  her 
children.  She  has  had  ten  children  and  nine  or  ten  miscarriages.  The 
children  whom  she  lost  all  died  of  convulsions  or  hydrocephalus.  The 
exciting  cause  of  her  illness  was  an  abortion  at  two  months.  She  was 
most  impulsive  on  admission  in  all  ways.  She  tore  her  clothes,  she  tried 
to  jump  out  of  windows,  she  refused  food  at  times  when  she  did  not  get 
what  she  wanted,  she  would  do  any  mischief  that  was  in  her  power.  Be- 
tween those  acts  she  was  rational  in  speech  and  conduct,  affectionate,  and 
agreeable.  She  would  be  dancing,  lively,  and  chatty  in  the  drawing- 
room,  apparently  one  of  the  happiest  women  there,  and,  seeing  an  open 
window,  she  would  suddenly  change  in  expression  of  face  and  eyes,  would 
step  towards  it,  and  try  to  throw  herself  over.  When  asked  about  it,  she 
would  say  she  could  not  help  it.  She  was  always  most  impulsive  at  the 
menstrual  periods,  and  at  these  times  frequently  had  retention  of  urine, 
needing  the  catheter  (this  she  had  been  subject  to  occasionally  during  her 
married  life).  The  bromides,  fattening  non-stimulating  foods,  fresh  air, 
baths,  and  constant  supervision  and  occupation  were  all  tried,  with  a 
gradual  good  effect.  The  impulses  became  less  intense,  and  her  self-con- 
trol more,  as  her  bodily  condition  improved.  She  was  subject  to  sudden 
feelings  of  what  she  described  as  "unutterable  dread  and  woe,"  coming 
like  a  flash  over  her  and  passing  away  as  quickly.  Unfortunately  at 
first  we  gave  her  chloral  and  hyoscyamus  at  night,  which  I  found  was  a 
mistake.  She  became  very  dependent  on  these  things  for  sleep.  She 
did  much  better  when  they  were  stopped.  Now  I  never  give  chloral  con- 
tinuously where  there  is  impulsiveness.  I  believe  that  its  effect  is  to 
lessen  the  inhibitory  mental  power  of  the  brain.  In  about  three  years 
she  had  improved  considerably,  and  was  removed  to  another  asylum ;  but 
she  is  impulsive  still  at  times,  though  not  dangerously  so.  It  must  be 
remembered  that  all  these  impulses,  obstinacies,  violences,  destructive- 
nesses,  and  suicidal  attempts  were  most  contrary  to  the  whole  habits  of 
the  life  of  this  lady  till  she  was  forty-seven,  that  they  then  lasted  more 
or  less  for  nine  years,  and  now  she  has  got  rid  of  them  to  a  very  large 
extent ;  and  that  between  those  acts  of  want  of  inhibition  she  was  one  of 
the  most  agreeable  and  sensible  persons  I  ever  saw,  and  was  clever,  witty, 
and  often  hilarious. 

The  next  case  was  a  patient  of  mine,  and  was  well  described  by  one 
of  the  assistant  physicians  here,  Mr.  James  Maclaren.^  I  look  on  it  as 
being  generally  impulsive  and  to  some  extent  epileptiform  in  character. 

"Late  one  night  a  lady,  whom  Ave  shall  know  as  E.  M.,  was  brought 
to  the  Royal  Edinburgh  Asylum,  laboring  under  great  excitement,  and 
bleeding  from  wounds  in  her  mouth,  caused  by  her  attempts  to  swallow 
pieces  of  the  glass  of  a  cab  window  which  she  had  broken.  Her  insanity 
was  very  early  seen  to  be  of  a  kind  in  which  the  leading  features  were 

^  Medical  Times  and  Gazette,  January  8,  1876. 


STATES    OF    DEFECTIVE    INHIBITION.  239 

impulsive  acts  of  a  sudden  and  a  most  dangerous  character  to  herself  and 
to  others.  She  is  not  an  epileptic ;  she  has  no  delusions  or  hallucina- 
tions, or,  if  she  is  possessed  with  the  former,  they  are  of  a  kind  belong- 
ing more  to  a  mild  state  of  dementia  than  anything  else,  and  are  fleeting ; 
and  she  has  at  any  time  only  occasional  and  often  no  consciousness  of  the 
irresistible  impulse  which  is  frequently  put  down  as  the  cause  of  danger- 
ous acts  otherwise  difficult  to  account  for.  In  her  the  paroxysm  of  vio- 
lence has  the  following  characters :  It  is  periodic  ;  it  is  accompanied  by 
always  partial,  frequently  total  unconsciousness,  and  consequently  fol- 
lowed by  a  similar  state  of  forgetfulness  of  her  acts ;  it  is  preceded  by 
sharp  pain  in  the  head,  and  followed  by  a  dull  pain  in  the  head,  dizzi- 
ness, and  confusion  of  ideas.  There  exist  also  certain  neuroses,  but  these 
will  be  detailed  in  the  course  of  the  history  of  her  case,  which  it  will  be 
well  now  to  enter  on. 

"  She  is  forty -three  years  of  age,  the  fifth  child  of  a  family  of  fourteen. 
Her  parents  are  both  of  a  neurotic  type ;  her  father  is  almost  totally  deaf, 
and  a  brother  of  his  died  insane.  That  is  not  a  very  strong "  neurotic 
history  perhaps,  but,  making  allowances  for  the  possible  reservations  of 
sensitive  relatives,  it  indicates  a  decided  tendency  to  nervous  weakness. 
Her  mother  dwells  on  the  border-land  of  insanity;  she  was  always  a 
person  of  very  peculiar  disposition,  suspicious,  unreasonable,  and  of  an 
exceedingly  high-strung  and  nervous  temperament.  This  was  her  con- 
dition previous  to  marriage.  Its  cares  and  troubles,  and  particularly  the 
mental  and  physical  wear  and  tear  involved  in  the  bearing  and  nursing 
of  fourteen  children,  told  badly  on  her.  Her  confinements  were  severe, 
and  after  them  she  was  subject  to  alarming  fioodings;  at  her  menstrual 
periods,  too,  the  hemorrhage  was  always  excessive.  That  all  this  told 
on  her  severely  was  noticed  by  her  friends  in  her  increasing  debility, 
nervousness,  eccentricity,  and  irritability  as  she  advanced  in  years,  and, 
to  anyone  who  could  read  the  lesson,  was  confirmed  by  Avhat  seems  to  me 
a  very  curious  fact.  She  had,  as  I  have  said,  fourteen  children.  The 
first  four  of  these  were  fairly  healthy,  and  are  still  living ;  then  came  the 
subject  of  the  present  note,  regarding  whose  mental  and  physical  health 
we  shall  presently  hear ;  and  after  her  came  nine  children,  all  of  whom 
are  now  dead.  The  elder  ones  lived  longest,  and  then,  as  the  mother 
grew  in  years,  and  the  strain  on  her  became  greater,  the  duration  of  the 
life  of  her  offspring  shortened.  It  is  true  that  none  of  them  died  di- 
rectly from  brain  disease ;  still  it  does  not  seem  too  much  to  assume,  with 
the  history  I  have  described,  that  the  parents  were  at  first  able  to  pro- 
create healthy  offspring,  that  this  began  to  fail  with  E.  M.,  and  that  after 
her  the  strain  became  greater  and  greater,  and  so  they  produced  children 
only  in  the  pooi'est  degree  endowed  with  the  power  of  living.  The  in- 
verse ratio  between  the  age  of  the  parents  and  the  duration  of  life  in  the 
offspring  seems  too  marked  and  definite  to  be  due  to  accident  or  chance. 
So,  then,  in  this  neurotic  couple  we  have  them  in  their  early  married  life 
transmitting  to  their  children  health,  later  on  insanity,  and  ultimately  a 
tendency  to  early  death. 

"And  here,  forestalling  its  position  in  the  history  of  her  case,  comes 
in  another  step  in  the  descent  and  progressive  degeneration.  E.  M.,  has 
become  pregnant  several  times — one  child  is  alive,  one  lived  a  few  months, 


240  STATES    OF    DEFECTIVE    INHIBITION. 

all  the  rest  were  born  prematurely.  The  child  which  is  alive  is,  as  re- 
gards his  mind  at  present,  precocious  and  talented,  writes  letters  in  a 
style  beyond  his  years,  reads  books  on  natural  science,  and  is  fond  of 
sketching  and  painting,  and  thought  exceedingly  gifted  by  his  friends. 
With  the  history  I  have  detailed,  and  after  this  description,  it  is  almost 
superfluous  to  say  that  he  is  stunted  in  body,  weak,  and  miserable,  and 
often  barely  kept  alive  by  constant  and  most  careful  nursing. 

"I  have  now  to  speak  of  the  personal  history  and  characteristics  of 
the  unfortunate  lady  who  is  the  subject  of  this  sketch.  As  I  have  said, 
she  was  the  fifth  child  of  her  parents.  In  her  eai-ly  years  she  was  only 
noted  for  everything  that  was  good  and  amiable.  In  this  I  am  not  taking 
the  words  of  possibly  too  partial  friends,  but  of  others  who  knew  her 
more  or  less  intimately ;  and  one  and  all  bear  testimony  to  the  fact  that, 
as  regards  the  possession  of  many  good  qualities,  she  Avas  far  above  the 
average.  Kind  and  loving,  very  gentle  and  quiet,  but  apt  to  become 
emotional  on  trifling  provocation;  devoted  as  far  as  her  strength  per- 
mitted to  all  good  works,  generous  even  to  a  fault,  and  earnest  in  season 
and  out  of  season  to  do  her  duty, — such  is  the  account  of  her  in  her 
early  days.  From  her  earliest  years  religion  was  part  of  daily  life,  not 
engrafted  on  to  her  other  duties,  but  forming  the  moving  principle  of  all 
she  did.  She  belonged  to  a  devout  family  and  a  devout  sect,  and  so,  by 
education  as  well  as  temperament,  was  thoroughly  and  entirely  devoted 
to  sacred  thoughts  and  duties,  and  was  noted  among  her  friends  for  the 
emotional  fervor  and  power  of  her  prayers.  In  ability,  too,  she  was 
above  the  average — clever,  studious,  and  painstaking. 

"At  the  age  of  twenty-three  she  married  her  present  husband — a  gen- 
tleman in  every  way  calculated  to  make  her  happy.  It  was  long  before 
he  noticed  anything  particularly  strange  in  her  manner  or  conduct.  Cer- 
tain slight  peculiarities,  a  morbid  sensitiveness  as  to  possible  wrong-doing, 
occasionally  excessive  emotionalism,  and  once  or  twice,  when  in  circum- 
stances calculated  to  excite  or  distress  her  (such  as  being  in  the  company 
of  uncongenial  people  or  those  of  a  higher  social  rank),  a  tendency  to 
become  rambling  and  incoherent, — these  were,  as  far  as  he  can  remember, 
the  only  facts  that  called  for  notice  or  excited  alarm.  Still  it  was  of  the 
slightest;  for  she  had  always  been  somewhat  unlike  other  girls  of  her 
age,  and  inclined  to  strange  and  wayward  (though  serious)  turns  of 
thought  and  expression ;  and  for  long  the  knowledge  of  this  prevented 
much  or  any  attention  being  paid  to  passing  acts  of  eccentricity  or  un- 
wonted modes  of  speech.  Excepting  these  (and  they  had  been  so  slight 
that  it  is  only  now,  on  close  inquiry  being  made,  that  they  are  recalled) 
she  for  long  after  she  was  married  led  the  same  kind  of  life  she  has  been 
described  as  doing  before,  and  was  foremost  in  every  good  work  and  kind 
action.  Still,  it  is  not  difficult  to  trace  the  gradual  invasion  of  the  malady 
of  which  she  is  now  the  victim. 

"  Some  years  after  she  was  married,  and  ten  years  ago,  the  boy  already 
mentioned  was  born,  but  previous  to  that,  and  since,  she  had  several 
times  aborted.  On  each  occasion  her  bodily  weakness  from  excessive 
flooding  was  great,  and  her  mental  distress  at  the  unfortunate  issue  very 
painful.  Two  years  ago  she  again  became  pregnant,  and,  greatly  to  her 
joy,  was  delivered  of  an  apparently  healthy  boy,  and  for  a  little  while 


STATES    OF    DEFECTIVE    INHIBITION,  241 

the  caring  for  it  seemed  to  restore  the  balance  of  her  mind.  However, 
it  was  only  spared  to  her  for  a  few  months,  and  its  death  and  the  final 
and  marked  access  of  her  insanity  occurred  to  her.  During  her  preg- 
nancy, and  for  some  months  before,  the  little  abnormalities  I  have  men- 
tioned were  beginning  to  become  more  and  more  marked.  Her  religious 
feelings  became  of  the  most  exalted  character,  and  her  emotionalism  ex- 
cessive. On  one  occasion,  while  walking  with  her  husband  in  a  fre- 
quented place,  she  knelt  down  and  prayed  for  strength  to  bear  her  coming 
trial ;  and  her  benevolence  and  generosity,  always  prominent  features  in 
her  character,  became  almost  unbounded,  and  frequently  quite  unreasona- 
ble. When  the  baby  came,  her  attention  was  taken  up  with  it,  to  the 
exclusion  of  everything  and  every  one  else.  Then  it  was  taken  away, 
and  from  that  time  is  dated  the  marked  unmistakable  arrival  of  the  in- 
sanity. General  excitement,  an  altogether  morbid  and  excessive  fear 
regarding;  her  religious  state  and  future  salvation,  and  an  excessive  sensi- 
tiveness  as  to  the  possibility  of  ever  having  in  any  way  wronged  any  one 
with  whom  she  might  have  had  dealings,  were  the  early  symptoms  she 
displayed.  Then  sudden  and  unaccountable  outbreaks  of  dangerous 
violence,  attempts  at  self-destruction  occasionally,  and  most  destructive 
tendencies  in  every  respect,  rendered  her  removal  to  an  asylum  impera- 
tive. She  was  accordingly  taken  to  a  private  establishment,  where  she 
remained  for  a  few  months,  gradually  getting  worse  and  worse.  During 
this  time  a  hsematoma  of  the  left  ear  developed  itself,  and  ran  the  usual 
course,  leading  to  the  shrivelled  and  characteristic  insane  ear.  She  waa 
brought,  as  I  have  said,  to  Morningside  last  July,  with  the  reputation  of 
being  a  patient  most  dangerous  to  herself  and  others,  and  requiring  con- 
stant and  careful  watching  and  supervision,  and  she  has  more  than  justi- 
fied all  that  was  said  of  her.  She  had  not  been  long  a  patient  before  it 
was  noticed  that  her  case  presented  many  points  of  singular  and  great 
interest.  Her  constant  and  seemingly  unwearied  attempts  to  commit 
some  destructive  act,  and  the  care  and  ingenuity  required  to  bafile  these, 
made  her  an  object  of  much  thought  and  no  little  anxiety;  but  quite 
apart  from  that,  which  is  not  so  very  rare  an  experience  for  an  asylum 
officer,  there  is  in  her  case  such  an  amount  of  strange  contradiction,  and 
contrast  of  light  and  shade,  as  to  make  her  a  puzzling  and  interesting 
study.  Instead  of  extracting  the  details  of  daily  entries  in  the  case- 
book, I  will  endeavor  to  give  a  brief  sketch  of  what  manner  of  woman 
she  is. 

"First,  as  to  her  appearance — she  is  slight  and  almost  undersized,  a 
very  gentle-looking  lady,  with  a  pale,  pretty  face,  light  hair,  and  blue 
eyes,  a  singularly  kind,  pleasant,  winning  manner,  and  a  soft,  quiet 
voice.  Second,  as  to  her  mental  state — free  from  excitement,  she  is 
"what  she  has  already  been  described  as,  thoroughly  devout  and  good. 
Her  memory  and  judgment  are  in  all  but  one  respect  correct.  Thoughts 
of  her  husband  and  child,  bitter  regret  at  her  separation  from  them  and 
at  her  sad  calamity,  a  constant  and  prevailing  desire  to  do  what  is  right, 
and  an  excessive  and  morbid  sensitiveness  lest  her  slightest  word,  or 
look,  or  action  may  be  in  any  way  wrong.  That  is  the  bright  side  of  the 
picture  of  a  singularly  pure  but  sadly  imperfect  nature.  Now  for  the 
reverse. 

16 


242  STATES    OF    DEFECTIVE    INHIBITION. 

"It  is  diflficult  in  a  pen-and-ink  sketch  to  give  an  idea  of  the  intense 
impulsiveness  of  her  acts.  I  am  not  at  all  exaggerating  when  I  say  that 
little  short  of  being  possessed  by  the  devil  would  account  for  her  conduct. 
She  will  sit  reading  her  Bible  or  some  good  book,  or  talking  in  her  quiet, 
gentle  way  to  her  attendant,  when  suddenly,  without  a  moment's  warning, 
the  book  is  flung  through  the  nearest  window,  or  at  whatever  is  breakable 
at  hand,  then  she  makes  a  rush  to  run  her  head  into  the  fire,  or  turns  on 
her  attendant,  tears  her  clothes,  or  tries  to  strangle  her.  All  this  without 
speaking  a  word,  except,  perhaps,  an  occasional  muttered  text  of  Scrip- 
ture; but,  beyond  that,  she  keeps  quite  silent,  and  struggles  on  quietly 
but  fiercely,  till  either  exhausted,  or  restored  by  some  apparent  process  of 
awakening  to  her  former  condition.  Excitement,  of  course,  there  is  in 
plenty,  but  it  is  very  different  from  that  associated  with  more  ordinary 
forms  of  mania.  There  is  no  noise  or  shouting;  her  eyes  are  fixed  and 
suffused,  her  face  flushed,  and  her  teeth  clenched,  and  every  muscle  is  on 
the  strain;  but  the  whole  time  she  is  perfectly  quiet,  and  struggles  on 
with  a  fixed,  determined  purpose  expressed  in  her  whole  manner,  but 
without  wasting  a  word. 

"There  is  no  use  dAvelling  too  long  on  the  various  destructive  acts  that 
she  has  committed.  I  might,  I  believe,  go  on  for  hours,  and  not  have 
completed  the  list.  Sufiice  it  to  say  that  there  is  hardly  a  method  of  at- 
tempting violence  that  the  mind  could  conceive,  that  she  has  not  had  re- 
course to.  At  one  time,  but  only  for  a  few  weeks,  her  acts  took  the  form 
of  exposure  of  her  person,  and  in  this,  too,  suddenness  was  the  marked 
feature.  I  have  seen  her  weeping  bitterly  at  the  sadness  of  her  lot,  and 
praying  for  some  help,  and  while  the  words  were  still  on  her  lips,  throw 
herself  on  the  ground,  and  pull  up  her  dress.  Once  or  twice  about  this 
time  there  was  a  slight  increase  of  her  general  excitement,  and  she  laughed 
and  talked  more  than  usual ;  but  as  a  rule  the  exposure  was  something 
altogether  different  from  the  ordinary  suggestive  act  of  an  erotic  female. 
This  tendency  to  exposure,  however,  did  not  last  long,  and  has  not  re- 
turned. 

"Now  as  to  the  nature  of  her  paroxysms.  Though  not  very  definite, 
there  is  no  doubt  that  there  is  a  certain  amount  of  periodicity  in  them. 
It  is  not  hard  and  fast,  but  her  attendants  notice  that  she  has,  as  they 
put  it,  a  good  day  and  a  bad  one,  or  two  good  days  and  two  bad  ones. 
The  suddenness  of  their  arrival  has  been  already  dwelt  on.  She  often 
suffers  sharp  pain  in  the  head  for  a  longer  or  shorter  time  previous  to  an 
attack,  but  the  transition  from  perfect  quiet  and  gentleness  to  her  wildest 
paroxysm  is  instantaneous.  Then  (and  this  seems  to  me  a  very  impor- 
tant point  in  her  history)  there  is,  as  a  rule,  entire  unconsciousness  and 
forgetfulness  of  what  passed  during  an  attack.  I  have  often  taken  her 
carefully  over  the  events  of  a  day  in  which  one  had  occurred,  and  in- 
variably found  her  correct  and  precise  in  every  detail  till  we  reached  the 
onset  of  the  seizure.  Then  all  was  a  blank,  and  she  only  remembered 
that  she  seemed  to  faint,  and  then  found  herself  lying  on  a  sofa  with  an 
aching  head,  and  conftised  and  stupid.  Occasionally,  and  if  her  seizure 
has  not  been  very  severe,  she  has  some  slight  recollection  of  her  act  and 
of  the  impulse  which  led  to  it,  and  the  latter  is  always  a  feeling  of  im- 
perative necessity  that  it  is  her  duty  to  do  as  she  has  done ;  but  in  by 


STATES    OF    DEFECTIVE    INHIBITION.  243 

far  the  greater  number  of  lier  attacks,  unconsciousness  during  and  after 
was  the  rule. 

"  There  are  a  few  physical  phenomena  connected  with  her  case  that  I 
will  now  mention.  The  insane  ear  has  already  been  recorded.  Her 
tongue  is  tremulous  and  points  markedly  to  the  right  side.  After  an 
attack  she  has  a  slight  stutter  and  thickness  of  speech.  The  right  pupil 
is  more  dilated  than  the  left.  During  a  paroxysm  both  pupils  dilate  and 
contract  constantly  and  independently  of  each  other,  so  that  sometimes 
one  and  sometimes  the  other  is  the  more  dilated.  Her  hair  is  exceed- 
ingly dry ;  her  temperature  is  normal,  with  a  steady  increase  of  two 
points  in  the  evening  over  the  morning  figure.  Her  menstruation  has 
not  returned  since  her  last  child  was  born.  Her  sensibility  is  at  all 
times  dulled ;  during  an  attack  it  is  greatly  impaired.  The  reflex  action 
of  the  cord  is  much  dulled. 

'•What  is  the  nature  of  her  insanity?  Her  attacks,  read  alone,  seem 
only  to  wact  one  factor — epilepsy — to  make  all  complete.  This,  though, 
is  wanting ;  she  is  not  epileptic  now,  and  has  never  been  so ;  and  her 
present  attacks,  though  bearing  not  a  little  resemblance  to  it,  are  not 
epilepsy.  That  her  motor  centres  and  the  circulation  in  her  brain  are 
diseased,  the  outward  signs  I  have  told  show,  but  that  only  leads  us  half- 
way, if  so  far.  Why  is  it  that  this  gentle,  loving  lady,  who  mourns  her 
affliction  so  greatly,  and  who  would  fain  struggle  against  it,  so  that  she 
might  return  again  to  her  husband  and  her  child, — why  is  it  that  at  the 
very  moment  she  is  penning  kind  words  to  them,  or  thinking  kind 
thousrhts  of  them,  she  should  be  dragged  into  the  committing;  of  acts 
Avhich  she  abhors,  and  of  which  she  is  happily  unconscious  ?  And  yet, 
though  in  her  calmer  moments  she  is  oblivious,  still  these  acts  were  gov- 
erned by  a  direct  controlling  will — they  had  an  object,  and  were  carried 
to  a  definite  end. 

"It  is  a  strange  condition  of  dual  consciousness.  Whether  she  re- 
members in  each  paroxysm  what  happened  in  the  last  I  cannot  say,  but 
I  think  she  does,  and  it  is  certain  that  she  follows  out  trains  of  thoughts 
in  successive  attacks,  of  which  she  has  no  consciousness  during  a  remis- 
sion. For  instance,  of  late,  as  soon  as  a  seizure  comes  on  her,  she 
makes  particular  efforts  to  get  at  one  special  picture  in  the  room.  'When 
the  attack  has  passed,  this  picture  awakens  no  feelings  in  her  at  all,  and 
she  has  no  recollection  of  anything  particular  connected  with  it ;  but  as 
soon  as  the  excitement  returns,  her  attention  fixes  on  it  at  once." 

In  the  course  of  three  years  she  gradually  became  less  dangerous,  and 
the  impulsive  attacks  less  intense,  while  her  mind  became  more  enfeebled. 
She  got  so  much  better  that  she  was  taken  home  under  the  charge  of  a 
nurse,  and  is  noAV,  after  seven  years,  almost  demented,  and  of  course 
quite  incurable.     The  impulsiveness  has  almost  disappeared. 

Epileptiform  Impulse. — Epilepsy,  as  we  shall  see  in  the  psychosis 
commonly  associated  with  it  (epileptic  insanity),  tends  remarkably 
towards  impulsive  acts,  which  will  be  considered  under  that  form  of 
insanity.  By  epileptiform  impulse  I  mean  those  sudden  impulsive  acts 
attended  by  unconsciousness,  Avhich  are  exactly  the  same  in  character  as 
those  we  are  familiar  with  in  epileptics,  and  yet  the  patients  are  not 
subject  to  ordinary  epilepsy.     Hughlings  Jackson,  I  suppose,  would  call 


244  STATES    OF    DEFECTIVE    INHIBITION. 

them  cases  of  mental  epilepsy.  Some  of  the  acts  of  E.  M.  were  clearly 
of  this  character.  I  have  now  a  patient  who  brought  on  his  disease  by 
over-drinking,  and  who  on  one  occasion  leaped  through  a  window  on  the 
third  story  when  quite  sober,  and  did  not  know  anything  about  it  after- 
wards. On  another  occasion,  in  passing  the  corner  of  a  building  in  the 
asylum,  he  ran  violently  against  it  with  his  head,  causing  a  wound  five 
inches  long,  and  very  nearly  breaking  his  skull-cap.  He  is  not  a  regular 
epileptic,  but  he  once  took  a  convulsive  epileptiform  attack.  His  case  is 
incurable,  as  he  is  now  getting  demented,  and  his  impulsiveness  is 
passing  off".  The  regular  use  of  the  bromide  of  potassium  seemed  to 
diminish  the  impulsive  tendency. 

Animal  and  Organic  Impulse. — Under  this  tenn  I  include  all  the 
nncontrollable  impulses  towards  sexual  intercourse,  masturbation,  sodomy, 
rape  on  children,  bestiality,  etc.  The  perverted  instincts,  appetites,  and 
feelings  shown  in  urine  drinking,  eating  stones,  rags,  clay,  nails,  etc., 
come  under  this  heading  too.  There  are  few  cases  of  mental  disease 
where  some  appetite  or  instinct  is  not  in  some  degree  perverted  or 
paralyzed.  But  there  are  cases  where  such  things  are  so  prominent 
as  to  constitute  the  disease.  I  have  a  patient  who  assures  me  that  his 
desire  to  masturbate  is  an  irresistible  craving  Avhich  he  has  no  power  to 
control.  Here  is  a  girl  who  rubs  her  thighs  together  to  produce  sexual 
excitement  the  moment  she  sees  a  man.  Here  is  a  case  of  nymphomania, 
who  rushes  towards  any  man  she  sees,  and  can  scarcely  be  held  by  two 
attendants.  I  believe  there  are  cases  in  which  there  are  irresistible 
impulses  towards  sodomy  and  incest.  Many  of  the  men  who  commit 
rape  on  children  are  insane.  I  lately  had  to  give  evidence  at  the 
Carlisle  Assizes  about  the  insanity  of  a  medical  man  who  had  tried  to 
commit  rape  on  three  children  under  age  in  succession.  No  doubt  he  had 
the  delusion  that  God  had  in  some  occult  way  revealed  to  him  that 
he  should  beget  a  male  child,  and  had  sent  the  little  girls  to  him  for  this 
purpose ;  but  he  was  practising  his  profession  up  to  the  commission 
of  the  act.  I  have  referred  to  the  case  of  the  young  woman  who  had  an 
impulse  to  eat  clay  and  dirt  every  time  she  menstruated.  She  could  not 
help  it,  and  had  no  such  tendency  between.  A  shoemaker  patient  in  the 
Prestwich  Asylum  swallowed  a  few  shoe-nails  every  day,  and,  what  was 
strange,  was  none  the  worse.  There  is  an  infinite  variety  of  such 
impulses.  Erotomania  is  applied  to  those  cases  where  there  is  an 
intensely  morbid  desire  towards  a  person  of  the  opposite  sex,  without 
reference  to  the  sexual  act.  It  is  a  sort  of  exaggerated  and  insane  state 
of  "being  in  love." 

Homicidal  Impulse. — Homicidal  impulse  is  often  spoken  of  by 
lawyers,  publicists,  and  ignorant  persons,  as  if  it  were  a  thing  that  did 
not  really  exist,  but  has  been  set  up  by  the  doctors  to  enable  real  criminals 
to  escape  justice.  Here  is  a  letter  from  a  former  patient  of  mine,  E.  N., 
a  medical  man  of  perfect  truthfulness  and  great  benevolence  of  character, 
written  to  me  when  he  was  convalescent : 

My  Deak  Sir, — According  to  promise,  I  have  written  to  the  hest  of  my  ability  what 
I  feel  mentall}'.  God  alone  knows  my  feelings.  They  are  truly  awful  to  know.  I  lived 
in  continual  fear  of  doing  harm  each  day.  I  had  not  a  moment's  peace  in  this  world. 
I  have  been  in  practice  for  twenty-three  yeai-s,  and  have  attended  2550  midwifery 


STATES    OF    DEFECTIVE    INHIBITION.  245 

cases,  which  used  to  take  the  life  out  of  me  more  than  anything  else.  I  often  used, 
when  busy,  to  attend  to  60  or  70  patients  a  day  at  home  and  out,  and  in  the  winter  used 
to  average  28  a  day  at  their  houses.  1  have  had  no  holiday  for  many  j^ears.  I  did  not 
think  I  was  laying  the  seeds  of  brain  disease,  but  such  has  been  the  case  in  the  most 
dreadful  form.  I  loved  my  dearest  wife  and  little  ones  most  dearly,  and  my  home  used 
to  be  so  happy  and  cheerful  after  my  hard  work.  You  are  aware  I  had  a  very  long  illness 
in  bed,  had  several  operations,  erysipelas,  &c.  Two  yeai-s  previous  to  this  I  had  a  fall 
on  my  head,  which  stunned  me  at  the  time.  I  may  say  I  have  never  felt  really  well 
since  the  fall,  though  I  did  mj-  practice.  I  had  occasional  strange  feelings,  but  those 
wei'e  only  known  to  myself,  being  ashamed  to  mention  them  ;  in  fact  all  the  time,  up 
to  within  a  short  time  of  coming  under  your  care,  I  appeared  cheerful  and  even  jolly. 
But  when  in  a  train  I  was  afraid  I  should  jump  out  of  the  window,  and  when  I  saw 
one  in  motion  I  felt  I  must  jump  under  it.  I  was  afraid,  when  applying  nitrate 
of  silver  to  the  throat  of  my  patients,  that  I  should  push  it  down.  I  was  terrified  to 
apply  the  midwifery  forceps,  lest  I  should  not  be  able  to  resist  the  impulse  I  had  to 
drive  them  up  through  the  patient's  body.     When  opening  abscesses  I  felt  as  if  I  must 

})ush  the  knife  in  as  far  as  possible.  When  I  sat  down  at  my  own  table  I  used  to  have 
lorrible  impulses  to  cut  my  children's  throats  with  the  carving  knife.  At  the  sight  of 
pins  I  had  a  feeling  as  if  some  had  got  into  my  throat,  and  I  could  not  divest  myself 
for  some  time  of  this  feeling.  I  had  other  strange  feelings  which  I  can  hardly 
describe.  W^henever  I  saw  a  knife,  razor,  gun,  etc.,  I  was  afraid  I  should  do  harm 
by  a  sudden  impulse,  the  will  having  hardly  the  power  to  resist.  I  took  opium 
several  times  from  no  deliberate  intention,  but  by  a  sudden  impulse  that  I  could  not 
resist  when  I  was  working  w'ith  it  in  the  surgery,  but  I  vomited  it. 

My  brain  feels  quite  dead,  with  no  feeling  in  the  scalp ;  my  eyes  seem  as  if  some- 
thing were  dragging  at  the  optic  nerve  continually.  In  the  left  I  have  a  most 
unpleasant  feeling  to  bear,  and  I  cannot  see  distinctly  with  it.  There  appears  to  be 
something  floating  in  front  all  the  time  like  a  dark  shade.  I  should  say  I  am,  and 
have  been,  suifering  from  homicidal  monomania  and  moral  insanity,  and  have  been 
since  June  last,  although  a  part  of  the  time  doing  my  practice  and  living  with  my 
family.     I  thought  I  could  shake  it  off,  but  such  was  unfortunately  not  the  case. 

Thanking  you  most  sincerely  for  the  kindness  and  attention  shown  to  me  since  I 
have  been  a  patient  in  this  asylum,  I  am,  dear  sir,  yours  faithfully,  E.  N. 

Now  this  is  either  a  tissue  of  lies,  or  the  thing  homicidal  impulse 
exists.  This  unfortunate  man  had  placed  himself  in  the  asylum  of  his 
own  accord,  and  he  took  a  gloomy  view  of  his  prospects  of  recovery.  I 
did  not  do  so,  but  assured  him  he  would  recover,  and  adopted  every 
means  for  that  purpose ;  gave  him  tonics,  got  him  employed  and  interested, 
made  him  live  in  the  fresh  air,  and  go  to  all  sorts  of  amusements  in  the 
asylum  and  out  of  it.  I  am  glad  to  say  he  recovered,  and  went  into 
practice,  and  unfortunately  got  as  much  to  do  as  ever,  and  relapsed. 
This  time  he  showed  his  impulsive  tendency  and  loss  of  inhibition 
by  taking  to  drink,  which  looked  like  a  symptom  of  his  brain  disorder. 
By  temperament  he  was  a  sanguine  man,  strong,  hearty,  robust,  and 
jolly.  In  fact  he  was  a  perfect  Mark  Tapley  in  his  unfailing  cheerfulness 
under  difficulties  and  disasters.  He  was  an  immense  favorite  with  the 
ladies  here,  and  to  see  "the  doctor"  being  taught  by  them  to  dance 
a  Scotch  reel  was  a  sight  far  away  from  any  suicidal  or  homicidal  idea. 
Yet  in  the  midst  of  this  a  dark  shadow  would  sometimes  cross  his  face, 
and  he  would  say  to  me,  "  Oh,  doctor,  these  strange  feelings ;  if  they 
would  only  keep  away  I  should  be  as  happy  as  I  look." 

This  is  merely  one  case,  but  it  is  a  typical  one.  E.  N.  had  no  insane 
delusions,  he  could  reason  well ;  affectively  he  was  fond  of  his  wife  and 
family  and  friends ;  he  had  not  a  cruel  or  criminal  disposition — quite  the 
reverse ;  he  had  no  outward  excitement,  no  signs  of  outward  depression 
like  an  ordinary  melancholic  patient ;  his  mind  was  not  enfeebled,  yet  he 


246  STATES    OF    DEFECTIVE    INHIBITION. 

wanted  to  kill  his  patients  and  his  children,  and  had  much  difficulty  in 
restraining  himself  from  doing  so,  and  he  actually  could  not  restrain 
himself  from  suicidal  acts.  All  these  feelings  were  connected  ■with  an 
original  heredity  to  mental  disease,  with  a  brain  exhausted  by  hard  work 
and  no  rest,  and  with  a  running  doAvn  of  his  general  vital  power  by  the 
bodily  disease  he  had  lately  suffered  from.  They  had  as  their  accompani- 
ments those  marked  sensory  and  special  sense  feelings  described  in  his 
letter,  which  were  really  an  essential  part  of  his  trouble.  They  disap- 
peared under  rest,  change,  proper  medical  and  moral  treatment.  The 
whole  affection  was  just  like  many  other  diseases  in  its  causation, 
inception,  and  recovery.  What  room,  therefore,  is  there  for  doubt  that 
such  a  disease  exists  ? 

That  the  theory  of  uncontrollable  homicidal  impulse  should  have  been 
used  in  courts  of  justice  to  screen  real  murderers  or  would-be  murderers, 
is  surely  no  reason  for  disbelieving  important  facts  of  disease.  It  is  our 
duty  as  medical  men  to  examine  carefully  the  evidence  in  every  case 
where  a  homicidal  impulse  theory  is  set  up  to  explain  crime,  to  look  on 
any  such  case  suspiciously  perhaps,  to  search  for  other  symptoms  and 
causes  of  mental  or  nervous  disease  accompanying  it,  but  we  must  not  be 
frightened  by  the  lawyers  into  blinking  real  facts  and  real  disease. 

Homicidal  impulses  in  a  mild  way  are  very  common  indeed  in  the  be- 
ginning of  mania  and  melancholia.  Patients  feel  as  if  they  must  kick 
and  strike  those  near  them,  and  they  often  do  so.  It  is  a  relief  to  them 
to  do  so.  Such  impulses  are  often  part  of  the  nervous  disturbances  that 
accompany  puberty,  disordered  menstruation,  childbirth,  lactation,  and 
the  climacteric  period  in  women.  I  once  saw  in  gaol  a  girl  of  thirteen, 
whom  I  had  no  doubt  had  without  motive  killed  a  child  entrusted  to  her 
care,  though  there  was  no  legal  proof  of  it.  Margaret  Messenger,  a 
little  girl  of  thirteen,  Avas  proved  at  the  Carlisle  Assizes,  1881,  to  have 
drowned  a  child  of  six  months,  of  which  she  had  charge,  and  she  had 
previously  killed  its  brother.  Like  all  such  cases,  she  had  no  motive, 
and  showed  no  mental  excitement  or  depression.  She  could  not  be  made 
to  realize  the  gravity  of  her  situation  or  the  awful  nature  of  the  crime 
she  had  committed.  This  paralysis  of  feeling  and  of  fear  is  very  char- 
acteristic of  such  cases.  She  was  described  as  "  a  typical  country  girl 
of  her  age,  fresh,  tidy -looking,  and  fairly  intelligent."  She  was  quite 
composed  through  the  trial.  After  her  conviction  she  confessed  that  she 
had  killed  the  brother  by  throwing  him  into  a  well,  in  which  it  had  been 
supposed  he  had  fallen  accidentally.  I  had  a  patient  last  year,  E.  N.  A., 
a  lady  with  a  child  five  months  old  when  I  saw  her,  and  who,  on  medical 
advice,  left  her  home  on  account  of  a  morbid  dislike  to  her  husband  and 
child,  and  homicidal  impulses  towards  them.  During  her  pregnancy  she 
had  the  same  kind  of  dislike  to  her  mother.  She  deplored  these  morbid 
desires  to  kill  her  husband  and  child  intensely,  because  she  was  devoted 
to  them,  and  a  most  affectionate  Avoman.  She  had  suicidal  impulses  too, 
but  not  so  strong.  These  were  not  the  only  symptoms  of  disease.  She 
suffered  from  dull  headaches,  twitchings  on  the  right  side  of  her  face 
when  she  spoke,  impaired  sleep,  fever,  slight  albuminuria,  aggravation  of 
all  her  symptoms  in  the  mornings,  screaming  fits,  want  of  appetite,  thin- 
ness, and  a  pigmented  skin.     Through  change,  absence  from  home,  milk 


STATES    OF    DEFECTIVE    INHIBITION."  247 

diet,  exercise  in  the  fresh  air,  iron,  claret,  and  pleasant  companionship 
and  travel,  she  recovered  in  about  four  months,  getting  stout,  fresh-col- 
ored, and  menstruation  becomino;  regular.  I  have  referred  to  the  case 
of  B.  R.  (p.  112),  a  climacteric  case,  and  her  tendency  to  kick,  strike, 
and  pinch  her  fellow-patients  in  the  morning  only,  while  in  the  evenings 
she  would  be  cheerful,  would  dance,  and  enjoy  herself.  I  have  now  a 
man,  E.  N.  B.,  with  a  neurotic  heredity,  an  uncle  being  epileptic,  who, 
when  sitting  at  a  window,  dropped  a  big  stone  on  to  the  top  of  the  head 
of  a  casual  passer-by,  against  whom  he  had  no  ill-feeling  whatever. 
After  he  was  sent  to  the  asylum  we  could  see  nothing  wrong  with  him 
till  one  day  he  tried  to  stick  a  dung  fork  into  an  attendant.  He  seemed 
to  recover,  and,  after  a  long  time  of  probation,  he  was  discharged,  but 
very  soon  ran  after  a  relation  with  an  open  knife.  He  was  sent  back  to 
the  asylum,  showed  no  signs  of  insanity  at  first,  and  then  his  mind  grad- 
ually became  enfeebled,  and  he  is  now  nearly  demented,  just  as  he  would 
have  been  had  his  attack  been  one  of  mania.  Homicidal  impulse  is  thus 
seen  to  end  in  dementia  if  it  lasts  long,  like  any  other  kind  of  mental 
disease.  I  have  even  seen  a  homicidal  stage  in  the  beginning  of  general 
paralysis. 

Suicidal  Impulse. — I  am  speaking  here,  remember,  of  suicide  as  an 
impulse  unaccompanied  by  any  marked  mental  depression  or  delusion. 
The  following  two  cases  exemplify  Avhat  I  mean : 

E.  0.,  a  young  man  of  eighteen,  of  nervous  heredity,  with  no  par- 
ticular cause  of  mental  or  bodily  disturbance,  except  perhaps  an  unre- 
quited love  fancy  for  the  scullery-maid.  He  being  an  assistant  to  a 
butler  in  a  gentleman's  family  in  Cumberland,  seemed  in  good  health,  in 
good  spirits,  and  was  washing  the  dishes  after  lunch  one  Sunday.  His 
master,  from  the  dining-room,  heard  a  peculiar  sound  in  the  pantry,  and, 
going  to  see  what  it  was,  found  E.  0.  hanging  by  the  towel  with  which 
he  had  been  wiping  his  dishes,  his  face  livid,  and  nearly  dead.  After 
being  taken  down  he  was  unconscious  for  some  hours,  and  then  confused 
in  mind  for  a  day  or  two.  He  was  sent  next  day  to  my  care  at  the  Car- 
lisle Asylum,  and  I  found  him  confused,  and  his  memory  defective.  He 
could  give  no  account  whatever  of  the  suicidal  attempt,  and  was  rather 
inclined  to  deny  it,  but  the  evidences  of  it  were  well  marked  on  his  neck 
and  face.  There  was  no  mental  pain,  and  no  delusion.  He  did  not 
sleep  very  well.  He  was  sent  much  into  the  open  air,  and  was  ordered 
a  little  bromide  of  potassium.  In  a  week  there  was  not  a  trace  of  any 
mental  defect  whatever.  He  was  not  a  strong-minded  youth,  but  not 
imbecile.  He  maintained  through  many  cross-questionings  that  he  never 
had  a  conscious  intention  or  thought  of  putting  an  end  to  himself  in  his 
life ;  that  he  remembered  events  quite  well  up  to  a  certain  moment  on 
the  Sunday  he  was  washing  his  dishes,  but  after  that  he  had  no  recollec- 
tion  of  anything  whatever  till  the  evening.  I  had  no  reason  whatever  to 
doubt  the  correctness  of  his  statements,  which  were  confirmed  to  me  by 
the  butler.     He  kept  quite  well  when  last  I  heard  of  him. 

E.  P.,  a  young  professional  man  of  thirty,  whose  father  had  been  sub- 
ject to  "depression  of  spirits,"  and  who  had  had  chorea  in  his  youth,  but 
who  was  clever,  cheerful,  good  principled,  religious,  and  successful.  He 
was  happily  engaged  to  have  been  married  in  a  fortnight.     He  had  been 


248  STATES    OF    DEFECTIVE    INHIBITION, 

spending  the  evening  with  some  friends,  and  was  in  first-rate  spirits. 
No  melancholy  or  morbidness  whatever  had  been  seen  in  him.  He  had 
remarked  to  some  friend  casually  some  weeks  before  that  he  had  to  hold 
his  head  in  a  particular  way  or  he  saw  things  double.  He  took  a  hearty 
supper,  and  went  to  his  bedroom.  In  the  morning  his  body  was  found 
suspended  to  a  cupboard  door  by  the  worsted  cord  of  the  window  curtain. 
He  had  undressed,  and  then,  evidently  without  preparation  or  contrivance 
of  any  kind,  taken  the  cord,  which  was  sewn  in  a  circle,  thrown  it  as  a 
loop  over  the  top  of  the  half-open  door,  put  the  other  end  of  the  loop 
under  his  chin,  and,  pulling  up  his  feet,  suspended  himself.  There  was 
a  strong  presumption  that  it  was  not  a  conscious,  premeditated  act.  We 
found  a  large  ossified  spiculum  of  bone  projecting  from  the  dura  mater 
into  a  convolution  at  the  vertex  at  the  junction  of  the  anterior  with  the 
middle  lobe,  the  arachnoid  thickened,  and  the  whole  brain  intensely  con- 
gested. I  considered  the  case  one  of  unconscious  suicidal  impulse  of  an 
epileptiform  nature.  Such  irritating  spicula  of  bone  of  course  often 
cause  ordinary  epilepsy,  and  this  is  not  the  only  case  of  impulsive  in- 
sanity in  which  I  have  met  with  the  same  pathological  appearances. 

Those  were  cases  of  morbid  suicidal  impulses  accompanied  by  uncon- 
sciousness. Such  cases  are  rare.  But  cases  like  the  following  are  very 
common  in  the  experience  of  most  medical  men.  The  classical  tedium 
vitce  was  somewhat  of  this  character,  looked  at  medico-psychologically. 

E.  P.  A.,  a  man  of  fifty-five,  who  had  been  healthy  and  lively.  For 
some  months  his  enjoyment  of  life  has  been  less  intense,  but  he  has  had 
no  real  mental  pain.  For  a  few  weeks  he  has  had  a  strong  impulse  to 
take  away  his  life,  and  the  sight  of  a  knife  at  once  suggests  this  to  his 
mind  at  any  time.  He  has  no  delusions  whatever  about  being  wicked, 
etc.  He  deplores  the  feeling,  and  it  annoys  him,  and  he  thinks  himself 
"a  fool"  for  harboring  "such  nonsense"  in  his  mind,  but  he  cannot  help 
it.  The  only  thing  wrong  with  him  is  this,  that  he  cannot  sleep  very 
well.  Change  of  air  and  scene,  after  about  two  years,  seemed  completely 
to  drive  away  the  suicidal  feeling,  but  his  mental  condition  after  it  passed 
ofi"  was  somewhat  senile,  his  ambitions,  desires,  and  enjoyments  being 
toned  down,  and  all  the  keen  edge  of  his  life  taken  off. 

When  the  impulse  is  towards  self-destruction,  even  the  lawyers  do  not 
deny  its  existence  or  try  to  reason  facts  away.  And  they  cannot  attri- 
bute any  sufiicient  "motive"  for  such  persons  as  E.  0.  and  E.  P.  putting 
an  end  to  themselves,  though  this  notion  of  a  "motive"  for  suicide  seems 
ineradicable  in  the  public  mind.  Who  ever  saw  an  account  of  a  suicide 
in  a  newspaper  without  an  explanatory  remark  that  "  the  motive  for  the 
rash  act  has  not  been  ascertained  ?"  It  is  impossible  to  tell  how  many 
of  the  sixteen  hundred  annual  suicides  of  England  are  the  result  of  mere 
impulse,  apart  from  mental  depression,  delusion,  or  alcoholism.  It  is 
common  to  find  the  suicidal  and  homicidal  impulses  combined,  as  in  the 
case  of  E.  N.  (p.  244),  to  which  I  have  referred. 

Destructive  Impulse. — In  childhood  there  exists,  from  pure  accumu- 
lation of  motor  energy,  that  must  be  let  off  somehow,  a  desire  to  play, 
to  romp,  to  move,  and  to  destroy.  Most  people  experience  a  morbid 
muscular  activity  when  they  have  "  the  fidgets,"  and  few  people  but  have 
the  feeling  sometimes  that  they  would  like  to  break  glass  or  smash  some- 


STATES    OF    DEFECTIVE    INHIBITION.  249 

thing.  In  many  forms  of  mania  and  in  excited  melancholia  Ave  have 
destructive  tendencies  as  one  symptom  of  the  general  psychosis.  In  high 
emotional  tension  women  often  feel  as  if  they  must  cry  or  break  some- 
thing, and  many  women  in  prison  take  regular  periods  of  "breaking 
out,"  during  which  they  tear  and  destroy  clothes  and  property  without 
regard  to  punishment  or  to  consequences.  In  the  first  stage  of  general 
paralj'sis  the  morbid  motor  activity  usually  takes  the  form  of  tearing,  and 
it  is  common  for  such  cases  to  have  all  their  blankets  torn  to  shreds  every 
morning,  and  their  clothes  during  the  day.  But  the  same  uncontrollable 
desire  to  tear  or  break  may  exist  alone,  without  much  outward  exaltation 
or  depression. 

I  have  now  a  young  man  of  twenty -five,  E.  P.  A.,  whose  mother  was 
insane  and  his  brother  paraplegic,  who  for  two  years  required  the  constant 
vigilance  of  an  attendant  to  prevent  him  breaking  windows  and  tearing 
his  clothes.  He  actually  broke  over  one  hundred  small  panes  of  glass, 
and  tore  one  hundred  and  fifty  pairs  of  trousers.  The  reason  he 
assigned  for  this  was  that  he  could  not  help  it,  and  that  it  was  "  my 
conscience  checking  me  "  that  did  it.  He  was  quite  sprightly  and  jolly, 
would  work  in  the  garden,  would  dance  at  the  ball  as  lively  as  anyone, 
and  was  never  suicidal  or  homicidal,  yet  when  he  saw  a  window  near, 
he  would  eye  it  as  if  fascinated,  and,  if  he  had  a  chance,  would  spring  at 
it  and  smash  it,  or  throw  something  at  it.  He  said  it  gave  him  great 
relief  when  this  was  done.  He  seemed  to  grow  out  of  this  tendency  as 
he  became  more  demented,  which  he  did  gradually.  The  habit  of  mas- 
turbation increased  the  tendency  in  him,  and  hard  work  in  the  garden 
ordinarily  diminished  it.  The  bromide  of  potassium  and  cannabis  Indica 
kept  it  in  check. 

I  show  you  another  patient,  F.  F.,  of  twenty-two,  who  suddenly  when 
at  sea  took  "smashing  fits,"  the  description  of  which  by  Dr.  Logic,  his 
family  medical  man,  was  as  follows  :  "  His  bodily  health  is  good,  but  he 
is  subject  to  sudden  fits  of  something  like  insane  impulse,  continuing 
sometimes  for  a  few  minutes  only,  and  at  others  for  a  whole  day.  During 
their  continuance  he  has  no  control  over  his  actions.  He  says  he  knows 
he  is  doing  something  which  he  ought  not  to  do,  but  he  cannot  help  it. 
At  one  time  the  presence  of  the  fit  is  manifested  by  his  roaring  aloud 
and  using  very  bad  language ;  at  another  he  will  suddenly  jump  up, 
seize  a  chair,  dash  it  with  violence  on  the  table,  smashing  to  atoms  dishes, 
cups,  and  saucers,  or  whatever  else  may  happen  to  be  on  the  table. 
When  in  these  states  he  is  exceedingly  violent.  When  interfered  with  on 
one  occasion  he  knocked  his  mother  down,  and  on  another  threatened  to 
shoot  his  father,  who  was  trying  to  control  him.  Unless  when  the  fits 
are  on  him,  he  is  perfectly  quiet  and  reasonable.  He  believes  that 
the  fits  are  occasioned  by  a  person  who  has  power  over  him,  and  can 
make  him  do  as  she  likes,  and  that  she  first  obtained  that  power  by 
putting  something  in  his  tea."  After  admission  he  would  be  rational  and 
self-controlled  before  these  attacks,  and  again  after.  He  still  has  the  ten- 
dency, though  it  is  less  intense  and  less  frequent.  As  the  period  of 
adolescence  is  passing  into  manhood  and  his  beard  is  growing,  I  expect 
him  to  recover.  I  watched  him  one  night  at  a  dance.  He  looked  absent- 
minded,  and  aimlessly  restless.     I  spoke  to  him,  and  he  answered  me 


250  STATES    OF     DEFECTIVE    INHIBITION". 

rationally.  He  looked  pale,  and  his  eyes  were  glistening.  He  stepped 
towards  a  window,  and  suddenly  smashed  it  with  his  hand,  causing 
a  wound.     At  once  he  seemed  to  get  calm  and  quiet,  and  felt  relieved. 

We  had  on  two  occasions  as  a  patient  in  Morningside  a  man  named 
James  Morrison,  who  at  intervals  of  several  years  had  left  his  home  in  a 
Fife  village,  where  he  worked  as  a  weaver,  and  had  gone  to  Glasgow 
once,  breaking  some  windows  in  the  Cathedral,  and  to  Edinburgh  twice, 
breaking  some  large  plate-glass  Avindows  in  shops,  always  quite  coolly,  by 
throwing  stones  at  them.  After  coming  to  the  asylum  we  could  scarcely 
ever  detect  any  symptoms  of  mental  disease.  He  seemed  to  have 
expended  all  his  morbid  energy  in  the  one  act  each  time.  He  was  a  man 
of  neurotic  heredity  and  good  character,  who  had  no  motive  for  getting 
into  goal.  Pie  always  said  he  could  not  help  smashing  windows ;  that 
the  desire  to  do  so  used  to  come  on  him  in  his  home  in  the  Fife  village, 
along  with  a  restless,  unsettled  feeling ;  that  he  did  not  break  the  windows 
in  the  houses  of  his  village  because  they  were  too  small  and  "  not  worth 
breaking."  It  evidently  would  have  given  no  satisfaction  to  his  morbid 
desire  to  break  them.  I  presume  his  was  just  a  strong  and  uncontrollable 
form  of  the  feeling  which  many  men  have  who  stand  before  a  big  plate- 
glass  window  Avith  a  cricket  ball  in  their  hands. 

Dipsomania. — This  is  a  misnomer ;  we  do  not  mean  an  insane  craving 
to  drink.  What  is  meant  is  a  morbid  uncontrollable  craving  for  alcohol 
and  other  stimulants.  What  we  really  want  is  a  good  word  to  express  the 
cravings  for  all  sorts  of  neurine  stimulants  and  sedatives,  as  well  as 
alcohol.  The  confirmed  opium  eater,  the  inveterate  haschisch  chewer, 
the  abandoned  tobacco  smoker,  are  all  in  the  same  category.  No  medical 
man  who  has  been  long  in  practice  can  doubt  for  a  moment  that  there  are 
persons  whose  cravings  for  these  things  are  uncontrollable,  and  who  have 
therefore  a  disease  allied  to  all  the  other  psychokinesiae.  Particularly 
the  morbid  craving  for  alcohol  is  common,  and  so  intense  that  men  who 
labor  under  it  will  gratify  it  without  regard  to  their  health,  their  wealth, 
their  honor,  their  wives,  their  children,  or  their  soul's  salvation.  Certain 
causes  predispose  to  it.  These  are  (1)  heredity  to  drunkenness,  to 
insanity,  or  the  neuroses ;  (2)  excessive  use  of  alcohol,  particularly  in 
childhood  and  youth ;  (3)  a  highly  nervous  diathesis  and  disposition 
combined  with  weak  nutritive  energy  ;  (4)  slight  mental  weakness  con- 
genitally,  not  amounting  to  congenital  imbecility,  and  chiefly  affecting 
the  volitional  and  resistive  faculties ;  (5)  injuries  to  the  head,  gross 
diseases  of  the  brain,  and  sunstroke;  (6)  great  bodily  weakness  and 
anaemia  of  any  kind,  particularly  during  convalescence  from  exhausting 
diseases ;  (7)  the  nervous  disturbances  of  menstruation,  parturition,  lacta- 
tion, and  the  climacteric  period ;  (8)  particularly  exciting  or  exhausting 
employments,  bad  hygienic  conditions,  bad  air,  working  in  un ventilated 
shops,  mines,  etc. ;  (9)  the  want  of  those  normal  and  physiological  brain 
stimuli  that  are  demanded  by  almost  all  brains,  such  as  amusements, 
social  intercourse,  and  family  life ;  (10)  a  want  of  educational  develop- 
ment of  the  faculty  and  power  of  self-control  in  childhood  and  youth ; 
(11)  the  occasion  of  the  recurrences  in  alternating  insanity,  or  the 
beginning  of  ordinary  insanity ;  being  coincident  in  a  few  of  these  cases 
with  the  periods  of  depression,  but  mostly  with  the  beginning  of  the 


STATES    OF    DEFECTIVE    INHIBITION".  251 

periods  of  exaltation ;  (12)  the  brain  weakness  resulting  from  senile 
degeneration.  More  than  one  of  these  causes  may,  and  often  do,  exist  in 
the  same  case. 

The  neurine-stimulant  craving  is  nearly  always  associated  with 
impulses  or  weaknesses  of  control  in  other  directions  in  by  far  the 
majority  of  the  cases,  while  there  may  be  no  insane  delusion.  Yet  all 
the  faculties  and  powers  that  we  call  moral  are  gone,  at  all  events  for  the 
time  that  the  craving  is  on.  The  patients  lie ;  they  have  no  sense  of 
self-respect  or  honor ;  they  are  mean  and  fawning ;  they  cannot  resist 
temptation  in  any  form ;  they  are  erotic,  especially  at  the  beginning  of 
an  attack';  they  will  steal;  the  affection  for  those  formerly  dearest  is 
suspended ;  they  have  no  resolution,  and  no  rudiments  of  conscience  in 
any  direction.  The  common  objection  to  reckoning  such  persons  among 
the  really  insane  is  that,  though  they  have  brains  predisposed  by  heredity, 
they  have  often  brought  this  condition  on  themselves  by  not  exercising  self- 
control  at  the  period  when  they  had  the  power  to  do  so  ;  but  this  applies  to 
many  cases  of  ordinary  insanity.  Another  reason  is  that,  when  deprived 
of  their  stimuli  for  a  short  time,  they  are  sane  enough  in  everything  except 
resolution  not  to  take  to  them  again.  The  effect  of  the  excessive  use  for 
a  long  period  of  nerve  stimuli  of  all  kinds  is  to  diminish  the  controlling 
power  of  the  brain  in  all  directions,  and  to  lower  its  highest  qualities  and 
finest  points.  The  brain  tissue  is  always  so  fine,  so  delicate,  and  so  sub- 
tile-working, its  functions  are  so  inconceivably  varied  and  so  high,  that 
under  the  most  favorable  circumstances  it  runs  many  risks  of  disturbances 
of  its  higher  functions.  But  when  we  have  a  bad  heredity,  a  bad  educa- 
tion, and  a  continuous  poisoning  with  any  substance  that  disturbs  its  cir- 
culation and  paralyzes  its  capillaries,  that  excites  morbidly  its  cells,  that 
proliferates  its  neuroglia,  thickens  its  delicate  membranes,  and  poisons  its 
pure  embedding  lymphatic  cerebro-spinal  fluid,  we  cannot  wonder  that 
its  functions  become  impaired  and  are  not  fully  or  readily  resumed  in  all 
things.  The  unfortunate  peculiarity  is,  that  while  we  may  restore  the 
bodily  and  even  the  nervous  tone  so  far  as  muscularity,  sleep,  and  sensory 
ftinctions  are  concerned,  we  have  the  utmost  difficulty  in  restoring  the 
higher  functions  of  self-control  and  morals  in  some  cases.  A  dipsomaniac 
when  at  his  worst  is  readily  recognized  to  be  so  really  insane  as  to  be  in 
a  fit  state  to  be  placed  under  the  control  of  others  for  proper  care.  When 
he  is  at  his  best — after  a  few  weeks'  compulsory  deprivation  of  his  brain- 
poison — he  is  so  like  the  rest  of  the  world  in  all  essential  things  that  it  is 
most  difficult  to  see  how  laws  can  be  framed  in  the  present  state  of  public 
feeling  and  medico-psychological  knowledge  to  deprive  him  of  his  liberty. 
We  cannot  regard  the  drink-craving  alone.  We  must  be  prepared  to  deal 
with  the  opium  eater,  insane  smoker,  chloral  taker,  gambler,  and  even 
many  thieves  and  insane  speculators.  The  state  of  brain  in  all  these  is 
the  same  in  its  essential  nature.  It  would  be  inconsistent  to  provide 
against  and  try  to  cure  the  one  without  including  the  others. 

I  shall  noAv  show  you  a  typical  dipsomaniac,  F.  B.  His  mother  had 
been  melancholic  at  one  time,  and  her  family  was  a  neurotic  and  insane 
one.  He  was  of  a  nervous  temperament  from  the  beginning;  a  flesh 
eater  from  a  child ;  precocious  and  quiet,  but  not  dogged  in  application ; 
vain  to  an  almost  morbid  extent,  and  in  some  points  not  endowed  with 


252  STATES    OP^    DEFECTIVE    INHIBITION. 

common  sense.  At  puberty  he  had  a  slight  attack  of  chorea.  About 
seventeen  he  showed  keen  social  instincts,  but  no  realization  of  the  serious- 
ness of  life.  Especially  the  nisus  generativus  was  periodically  so  strong 
as  to  be  difficult  of  control,  and  he  did  not  control  it.  Being  a  "jolly 
fellow,"  and  mixing  with  such,  he  took  alcoholic  stimulants  of  all  kinds 
very  freely,  and  showed  a  very  great  fondness  for  them.  He  occasion- 
ally got  drunk.  About  twenty  he  was  addicted  to  bouts  of  drinking  and 
whoring,  which  came  on  periodically,  and  seemed  to  pass  off  and  leave 
him  fit  for  his  work.  He  was  ashamed  of  them  afterwards,  and  I  believe 
very  often  by  his  volition  and  self-control  did  not  at  this  time  indulge  in 
them  even  when  he  craved  them.  At  twenty-two  he  was  very  distinctly 
worse.  He  had  less  power  of  applying  himself  to  anything.  He  took 
almost  regularly  recurring  periodic  bouts  of  drinking,  during  which  the 
craving  for  alcohol  was  intense  and  quite  irresistible.  I  have  known  him 
drink  turpentine,  eau-de  Cologne,  and  chloroform  when  he  could  not  get 
alcohol.  He«was  nervous,  tremulous,  and  unable  for  any  kind  of  work 
while  the  fit  lasted.  He  would  lie,  cheat,  steal,  and  associate  with  the 
lowest  characters  at  those  times.  When  he  recovered  he  was  facile, 
lacking  in  conscientiousness,  and  somewhat  unveracious,  though  a  charm- 
ing companion.  All  sorts  of  things  were  tried — long  sea  voyages,  a 
colony,  isolation  in  a  doctor's  family — but  no  permanent  improvement 
was  produced.  He  sank  lower  and  lower  mentally  and  morally,  till  at 
thirty  he  was  really  weak-minded  and  unfit  for  respectable  people  to  asso- 
ciate with,  and  unable  to  do  any  work  of  any  kind.  Not  an  atom  of 
self-respect  was  left  in  him.  He  is  now,  at  forty,  in  a  mild  state  of  de- 
mentia. 

That  is  one  type  of  dipsomania.  I  have  only  known  two  such  who 
recovered.  Treatment  is  usually  begun  too  late.  In  reality,  youths 
with  such  a  constitution  of  brain  should  live  on  milk  and  farinaceous  food 
in  childhood,  should  not  be  brought  up  in  cities,  should  never  touch  al- 
cohol, should  be  trained  in  strictest  morality  and  with  little  temptation, 
should  marry  early  if  possible  if  the  drink-craving  has  not  been  awakened, 
and  should  not  lead  exciting,  hard  lives.  After  they  have  become  dipso- 
maniacs, in  the  present  state  of  the  law  that  does  not  allow  legal  inter- 
ference with  their  liberty — I  say  it  with  deliberation — the  sooner  they 
drink  themselves  to  death  the  better.  They  are  a  cui*se  to  all  who  have 
to  do  Avith  them,  a  nuisance  and  a  danger  to  society,  and  propagators  of 
a  bad  breed.  The  essential  texture  and  working  of  such  brains  are  bad, 
just  as  much,  but  in  a  difierent  way,  as  an  ordinary  insane  man's.  Such 
cases  may  be  called  dipsomaniacs  by  natural  development.  There  is  an 
essential  weakness  of  mind  underlying  that  sort  of  case. 

Here  is  another  kind  of  case.  F.  C,  a  married  woman  ;  the  mother 
of  a  large  family.  She  was  quite  well,  and  showed  no  drink-craving 
till  she  was  thirty.  When  pregnant  with  her  sixth  child  (the  three  pre- 
vious children  having  been  all  born  and  suckled  within  five  years,  all  her 
labors  being  hard,  and  in  one  case  with  post-partum  hemorrhage)  she  be- 
came quite  suddenly  changed  mentally  and  morally.  She  got  careless, 
slovenly,  lazy,  self-indulgent,  neglectful  of  her  children  and  family  duties, 
evidently  not  so  fond  of  her  husband  and  children,  irritable,  and  un- 
truthful.    In  addition  to  all  this  she  took  to  smoking  and  drinking. 


STATES    OF    DEFECTIVE    INHIBITION.  253 

This  continued  till  three  months  after  the  birth  of  her  child,  when  she 
became  slightly  depressed  for  two  or  three  months,  and  was  then  quite 
well  till  next  pregnancy.  The  same  condition  that  I  have  described  came 
on  again.  It  has  come  on  and  gone  off  with  a  certain  regularity  fifteen 
years  now^  I  expect  it  to  cease  at  the  climacteric  period.  She  has  had, 
by  the  way,  two  attacks  of  convulsions.  This  form  of  dipsomania  I  look 
on  as  one  form  of  alternating  insanity. 

Here  is  a  third  kind  of  case.  F.  D.,  an  educated  professional  man, 
whose  heredity  I  could  not  ascertain,  who  had  worked  very  hard,  and 
had  been  most  successful;  a  man  of  power,  of  a  nervous,  enthusiastic 
temperament,  and  of  great  natural  endurance  and  capacity  for  work. 
He  took  too  little  holiday,  and  unfortunately,  from  a  mistaken  idea  of  its 
real  use,  took  to  alcohol  to  restore  his  weariness,  keep  himself  up  to  his 
work,  and  produce  sleep.  It  seemed  to  do  all  those  things  at  first.  But 
he  soon  could  not  work  or  sleep  without  it,  and  it  lost  its  power,  so  that 
he  had  to  take  more  and  more,  and  oftener  and  oftener.  At  last  he  got 
absolutely  dependent  on  it,  but  it  would  not  make  him  work  enough. 
He  took  big  doses,  and  had  an  attack  of  acute  alcoholism.  After  this 
he  pulled  up,  but  only  for  a  time,  and  he  took  to  it  again  with  the  firmest 
resolve  to  restrict  himself  to  small  doses.  In  six  months  he  was  as  bad 
as  ever,  and  had  several  severe  alcoholic  convulsions.  This  occurred 
again  and  again,  and  he  became  temporarily  maniacal,  with  all  the  motor 
symptoms  of  alcoholism.  He  got  better  of  this,  took  to  drink  again,  and 
had  convulsions,  mania,  and  alcoholism.  Morally  he  was  weak,  un- 
truthful, and  unreliable,  but  never  so  bad  as  the  youthfully  developed 
dipsomaniac  F.  B.  He  died,  after  a  few  years,  demented,  and  with  par- 
tial paralysis  of  the  diseased  membranes  and  arteries  and  the  softened 
degenerated  brain  neurine  that  usually  follows  the  continuous  excessive 
use  of  alcohol. 

That  is  a  case  of  dipsomania  caused  simply  by  the  excessive  use  of 
alcohol  in  an  originally  good  sound  brain.  There  is  much  hope  in  such 
cases  if  taken  in  time,  if  they  can  then  be  made  to  see  the  importance  of 
absolutely  abstaining  from  alcohol  altogether.  The  continuous  use  of  the 
bromide  of  potassium  I  have  found  most  useful  in  such  cases.  It  dimin- 
ishes the  intensity  of  the  craving,  and  lessens  the  excitability  of  the 
brain.  Never  in  this  nor  any  other  class  of  insane  drunkards  think  of 
tapering  off  the  drink.  Knock  it  off  at  once,  and  completely.  I  never 
saw  any  bad  result  from  this. 

The  moral  treatment  and  management  of  dipsomaniacs  is  now  one  of 
the  most  unsatisfactory  things  a  medical  man  has  to  undertake.  The 
relations  and  friends  of  some  patients  will  implore  you  to  do  something 
or  recommend  something ;  yet  nothing  can  in  most  cases  be  done.  Lu- 
natic asylums  are  certainly  not  the  proper  places  for  them,  and  when 
sent  there  they  cannot  be  kept  long  enough  to  do  them  any  good.  What 
we  want  is  an  island  where  whiskey  is  unknown ;  guardianship  com- 
bining authority,  firmness,  attractiveness,  and  a  high  bracing  moral  tone ; 
work  in  the  open  air;  a  simple  natural  life;  a  return  to  mother  earth 
and  to  nature ;  a  diet  of  fi'uits,  vegetables,  bread,  milk,  eggs,  and  fish ; 
no  opportunity  for  one  case  to  corrupt  another ;  and  suitable  punishments 
and  deprivations  for  offences  against  the  rules  of  life  laid  down — all  this 


264  STATES    OF    DEFECTIVE    INHIBITION. 

continued  for  several  years  in  each  case,  and  the  legal  power  to  send  pa- 
tients to  this  Utopia  for  as  long  as  medical  authority  determines,  with  or 
without  their  consent.  That  would  be  the  ideal  mode  of  treatment.  In 
real  life  the  best  thing  we  can  do  is  to  send  our  cases  to  distant  fiirms  or 
manses,  or  doctors'  houses  in  remote  parts  of  the  Highlands  and  Islands 
under  a  firm  moral  guardian.  I  am  very  sceptical  about  institutions  for 
dipsomaniacs  where  many  of  them  are  together.  In  that  case  the  moral 
atmosphere  tends  to  be  low,  the  patients  keep  each  other  in  countenance, 
you  cannot  restore  the  sense  of  shame  and  of  self-respect,  and  they  plot 
and  fan  each  other's  discontent.  If  an  ordinary  dipsomaniac  does  not 
want  to  be  cured,  no  power  in  heaven  or  earth  will  cure  him.  In  that 
case,  no  law  permitting  forcible  seclusion  will  do  any  permanent  good  in 
the  way  of  cure.  It  is  easy  in  many  cases  to  produce  a  temporary 
amendment,  to  rouse  a  sense  of  shame  and  regret  for  the  time  being  ; 
but  what  is  the  use  of  that  when  they  return  to  the  world,  if  there  is  no 
power  of  inhibition  against  the  first  glass,  and  when  the  first  glass  creates 
an  irresistible  craving  for  the  second  ? 

Kleptomania.  —  This  interesting  variety  of  uncontrollable  impulse 
seldom  exists  alone  without  other  morbid  mental  symptoms  being  present. 
The  mere  desire  to  appropriate  for  one's  self  what  does  not  belong  to  one 
is  an  instinct  strongly  developed  in  the  animal  kingdom,  in  primitive  and 
savage  man,  in  children,  and  in  many  kinds  of  mental  disease.  Imbeciles 
appropriate  and  hide  what  they  fancy,  just  as  jackdaws  do.  The  desire 
is  there,  and  there  is  no  inhibition.  In  general  paralysis  appropriation 
of  all  kinds  of  things  is  most  common.  I  have  now  a  patient  who  every 
day  stuiFs  his  pockets  with  rags,  stones,  bits  of  glass,  broken  pottery,  etc., 
till  he  looks  as  if  he  had  a  meal  bag  on  each  side  of  him.  Every  night 
his  attendant  throws  these  things  away,  but  the  process  is  repeated 
next  day.  I  once  found  a  general  paralytic  trying  to  stuff  the  coal- 
scuttle into  the  backside  of  his  trousers.  Some  demented  patients  steal 
everything  they  can  lay  their  hands  on.  I  have  never  myself  met  with 
a  pure  case  of  kleptomania  without  other  mental  symptoms. 

Pyromania. — A  good  deal  has  been  written  on  the  morbid  tendency 
to  set  things  on  fire.  There  is  no  doubt  that  it  exists,  but  there  is  more 
doubt  about  its  existing  alone  without  other  symptoms  of  insanity.  I 
now  show  you  a  marked  example  of  the  disease,  combined  with  some 
melancholic  depression  of  mind,  and  with  one  or  two  delusions. 

F.  E.,  aet.  59  on  admission.  The  cause  of  her  attack  was  mental 
distress  at  a  sister's  becoming  insane  and  dying  in  the  asylum.  She  was 
melancholic  and  suicidal  on  admission,  and  had  delusions  that  she  had 
been  guilty  of  great  crimes.  A  first  she  tried  to  commit  suicide  by  tying 
pieces  of  cloth  round  her  neck  to  choke  herself  with.  In  six  months  her 
mental  condition  assumed  the  form  of  an  intense  desire  to  set  things  on 
fire,  to  set  her  clothes  on  fire,  to  burn  the  house.  She  became  impul- 
sively violent  at  times.  She  set  fire  to  her  hair  one  day,  another  day 
rushed  into  a  dormitory,  shut  the  attendant  out,  shovelled  the  live  coals 
from  the  fire  on  to  a  mattress,  threw^  herself  among  the  burning  mass, 
and  pulled  another  mattress  on  the  top  of  her,  severely  burning  herself, 
and,  in  fact,  nearly  losing  her  life.  She  sits  saying  to  herself,  "  I  maun 
mak  them  low"  (I  must  set  them  on  fire),  day  by  day.     In  four  years 


STATES    OF    DEFECTIVE    INHIBITION.  255 

this  impulse  to  burn  became  less  intense,  and  she  was  more  enfeebled  in 
mind,  and  in  about  six  years  after  admission  she  was  thought  to  have  got 
quite  over  it;  but  one  night  she  went  into  a  dormitory  and  set  all  the 
bedding  on  fire  from  a  gas-jet,  but  did  not  attempt  to  burn  herself  or  her 
clothes.  Now,  at  the  end  of  nine  years,  she  is  demented,  but  still  has 
the  remains  of  the  old  impulse,  though  in  a  very  slight  degree  indeed. 

I  was  once  asked  to  see  a  man  called  J.  F.  Wilson,  who  was  in  the 
Edinburgh  gaol  on  a  charge  of  fire-raising,  having  at  two  places  set  fire 
to  stackyards.  I  found  that  he  had  once  undergone  punishment  for  a 
similar  oifence,  and  that  on  being  taken  up  on  this  occasion,  when  going 
with  the  police  sergeant  to  the  station,  he  remarked  on  passing  a  big 
haystack:  "That  would  make  a  fine  blaze."  I  found  him  to  be  a  case 
really  of  delusional  insanity  Avith  a  good  deal  of  general  enfeeblement  of 
mind  and  hallucinations,  hearing  voices  telling  him  to  commit  rape,  and 
the  voices  and  screams  of  old  friends  often  in  the  night.  In  addition  to 
a  desire  to  set  things  on  fire,  the  sight  of  which  gave  him  pleasure,  a 
female  he  had  once  known  often  said  to  him,  when  he  was  thinking  of 
doing  so,  "If  you  are  to  do  so,  do  it  quickly."  I  considered  the  causes 
of  his  disease  to  have  been  heredity,  drinking,  and  syphilis.  He  had 
suffered  from  one  attack  of  mania,  for  which  he  had  been  in  Colney 
Hatch  Asylum.  I  did  not  think  he  had  any  chance  of  recovery.  He 
was  found  insane,  and  sent  to  the  lunatic  department  of  Perth  Prison, 
but  was  discharged  recovered.  Within  a  few  months  he  again  set  some 
stacks  on  fire.  This  time  I  could  discover  no  symptoms  of  insanity  about 
him,  but  a  slight  general  mental  enfeeblement,  and  he  received  sentence 
as  an  ordinary  criminal. 

The  majority  of  the  cases  Avhere  an  impulse  to  set  things  on  fire  is  the 
chief  symptom  of  mental  impulse  have  been  young  persons  about  the  age 
of  puberty  and  adolescence,  of  strong  nervous  heredity.  In  such  patients 
it  is  merely  another  manifestation  of  that  morbid  impulsiveness  and  "  in- 
stinctive" action,  of  which  the  homicidal  impulse  that  I  have  described 
is  the  most  marked  example. 

Moral  Insanity.  —  The  morals  and  affections  are  lost  or  become 
altered  in  many  forms  of  insanity.  The  question  is — Have  we  any 
examples  where,  from  disease,  a  man  who  had  up  to  that  time  been 
moral  and  conscientious,  and  obeyed  in  his  conduct  the  laws  and  the 
social  observances,  had  lost  his  moral  sense  while  he  retained  his  intelli- 
gence and  reasoning  power,  having  no  mental  exaltation  or  depression, 
and  in  consequence  of  that  diseased  moral  condition,  spoke  and  acted 
immorally?  Further  comes  the  question — Can  he,  when  the  diseased 
condition  is  cured  or  recovered  from,  regain  his  former  morality  in  feeling 
and  conduct?  I  have  no  hesitation  whatever  in  answering  both  questions 
affirmatively,  because  I  have  seen  such  cases.  It  is  not  a  question  of 
theory,  but  of  fact.  A  third  question  arises — Do  we  meet  Avith  children 
so  constituted  that  they  cannot  be  educated  in  morality  on  account  of  an 
innate  brain  deficiency,  rendering  them  incapable  of  knowing  the  differ- 
ence between  right  and  wrong,  of  following  the  one  and  avoiding  the 
other,  of  practising  checks  on  inclination,  of  exercising  self-control  or 
obedience  to  the  laws  of  God  and  man,  of  any  love  and  cultivation  of  the 
good,  or  any  dislike  of  evil?     Such  moral  idiots  I,  like  others,  have  met 


256  STATES    OF    DEFECTIVE    INHIBITION. 

with  frequently.     Persons  with  this  disease,  and  persons  with  this  want 
of  development,  we  say  labor  under  moral  insanity. 

Conscientiousness,  the  sense  of  right  and  Avrong,  is,  to  a  large  extent, 
an  innate  brain  quality.  We  see  this  in  children  from  the  earliest  age. 
Some  have  it  strongly,  without  teaching  or  example ;  others  have  it  spar- 
ingly, and  need  the  most  assiduous  care  to  develop  it.  I  have  referred 
to  a  morbid  conscientiousness  that  is  sometimes  seen  at  early  ages  in 
children,  and  in  some  of  them  is  followed  by  a  paralysis  of  the  sense  at 
later  periods  of  life.  I  was  once  consulted  about  a  boy  (F.  H.)  of  ten, 
not  an  idiot  or  an  imbecile,  and  quick  intellectually,  who  could  not  be 
taught  morality.  He  really  seemed  incapable  of  knowing  the  difference 
between  a  lie  and  the  truth,  or,  at  all  events,  he  never  could  be  got  to 
avoid  the  one  and  tell  the  other.  And  he  lied  without  any  temptation, 
and  with  no  object  to  be  gained.  His  statements  as  to  the  most  ordinary 
matters  of  fact  were  never  believed,  merely  because  he  made  them.  He 
stole;  he  had  little  proper  affection  for  his  brothers  and  sisters  and 
parents;  he  was  incapable  of  the  sense  of  shame.  When  punished  or 
scolded  he  became  mentally  paralyzed  and  in  a  condition  of  stupor,  in- 
capable of  knowing  or  doing  anything  whatever.  As  this  boy  approached 
puberty  he  developed  some  moral  sense.  His  grandmother  had  been 
insane.  I  knew  a  boy,  F.  I.,  one  of  a  very  neurotic  family.  Grand- 
mother insane,  father  a  dipsomaniac,  and  two  sisters  melancholies,  and 
other  two  with  various  neuroses,  who  was  untruthful  and  immoral  instinc- 
tively. No  one  who  knew  him  ever  believed  a  word  he  said.  He  stole, 
he  had  small  affective  power,  and  he  never  seemed  to  see  why  anybody 
should  be  offended  at  acts  of  immorality  or  dishonor.  He  was  carefully 
and  religiously  brought  up.  In  after-life  he  turned  out  a  selfish  and 
negatively  immoral  man.  He  never  paid  any  debt  that  he  could  help, 
and  he  borrowed  from  everyone  he  could.  He  treated  his  relations  badly. 
He  on  several  occasions  did  public  acts,  that  might  have  brought  him 
under  the  cognizance  of  the  criminal  law.  He  did  these  things  in  a 
stupid  way,  as  if  he  himself  was  quite  unconscious  he  was  doing  wrong. 
Such  cases  are  the  bane  and  disgrace  of  their  friends  and  families,  and 
the  skeletons  in  the  closets  of  their  relations.  Nothing  can  be  made  of 
most  of  them  morally,  any  more  than  a  genetous  idiot  can  be  converted 
into  an  active-minded  man.  Wrong  is  right  to  them :  they  prefer  lies  to 
truth,  immorality  to  morality.  I  knew  one  such  case  (F.  K.)  who  was 
continually  breaking  every  commandment  of  the  decalogue.  He  went 
through  a  form  of  marriage  with  four  women,  to  each  of  the  last  three 
having  told  that  he  was  unmarried,  and  I  just  saved  the  fifth  by  a  few 
hours  from  going  through  a  form  of  marriage  with  him !  Several  members 
of  his  family  had  been  insane,  and  others  subject  to  various  neuroses. 
He  took  his  heredity  out  in  immorality. 

The  occurrence  of  moral  insanity  as  a  disease  in  those  who  have  pre- 
viously had  the  moral  sense,  and  have  exercised  self-control,  without  at 
the  same  time  the  presence  of  morbid  mental  exaltation  of  some  sort,  is^ 
not  in  experience  so  common  as  the  want  of  a  moral  sense  from  con- 
genital deficiency.  Pritchard  quoted  many  such  cases,  and  vividly  de- 
scribed the  disease,  but  I  should  place  most  of  his  cases  in  my  category 
of  simple  mania,  like  C.  B.,  C.  C,  and  C.  F.  (pp.  128,  131,  133). 


THE    INSANE    DIATHESIS.  257 

There  was  distinct  mental  exaltation  along  with  the  loss  of  moral  sense. 
But  in  the  following  case  there  was  no  apparent  exaltation  : 

F.  L.,  aet.  37,  a  lady  of  mixed  race,  her  father  having  been  English 
and  her  mother  of  a  distinguished  Hindustani  family.  Up  to  the  age  of 
thirty  she  had  been  as  other  women,  had  married,  borne  children,  and 
conducted  her  affairs  discreetly  under  many  difficulties.  About  that  time 
she  entirely  changed,  morally  and  affectively,  without  intellectual  per- 
version and  without  mental  elevation  or  depression.  She  went  to  a 
distant  part  of  the  country,  where  she  was  not  known,  got  acquainted 
with  various  persons  there,  especially  fascinating  one  poor  gentleman  of 
a  benevolent  disposition.  She  said  she  was  the  heiress  to  vast  estates  and 
to  a  title.  Through  this  gentleman  she  got  introduced  to  other  persons, 
some  of  whom  believed  her  impossible  stories.  She  carried  out  impos- 
tures most  daringly  and  cleverly.  She  got  introduced,  or  introduced 
herself,  to  one  great  nobleman  after  another.  She  imposed  on  the 
Secretary  of  State  for  India  by  sheer  impudence  and  lies.  She  went  to 
a  public  meeting  where  she  knew  a  nobleman  of  philanthropic  zeal  was 
to  speak,  told  the  doorkeeper  she  was  an  intimate  friend  of  his,  and  was 
shown  into  the  private  room  reserved  for  him  ;  told  him  when  he  arrived 
that  it  was  she  who  was  the  great  support  of  the  movement  about  which 
he  was  to  speak  in  the  district,  was  taken  and  seated  by  him  on  the 
platform,  and  so  got  introduced  to  many  other  distinguished  persons. 
She  raised  large  sums  of  money,  amounting  altogether  to  many  thousands 
of  pounds,  on  no  security  whatever.  She  furnished  many  houses  most 
extravagantly  at  the  expense  of  trusting  upholsterers,  and  she  got  posses- 
sion of  jewellery  to  a  large  amount.  To  one  person  she  was  a  great 
literary  character  (and  she  did  have  printed,  at  other  people's  expense, 
a  volume  of  other  people's  poems  as  her  own),  to  another  she  was  of  royal 
descent,  to  another  she  had  immense  expectations,  to  another  she  was  a 
stern  religionist.  All  this  was  the  prelude  to  an  attack  of  hysteria,  brain 
softening,  and  spinal  disease,  of  which  she  died  in  a  year,  demented  and 
paralyzed.  And  one  of  the  most  astounding  things  was  that  her  first 
benevolent  patron  believed  in  her  to  the  last,  came  to  see  her  in  the 
asylum,  and  was  going  to  write  her  biography  as  that  of  the  most  won- 
derful woman  he  had  ever  come  across — this  being  a  decent  middle-class 
man,  who  by  his  honest  industry  had  made  a  small  fortune,  and  had  lost 
X3000  of  it  through  her.     And  he  was  counted  sane  and  she  insane ! 


THE    INSANE    DIATHESIS. 

A  description  of  the  general  symptomatological  forms  of  mental  dis- 
orders would  not  be  complete  without  reference  to  a  condition  of  mentali- 
zation  which  has  been  called  the  insane  diathesis.  Maudsley,  in  this 
country,  and  Morel,  in  France,  have  described  it  better  than  any  other 
authors.  The  great  difficulty  about  its  description  is  that  we  find  few 
cases  of  this  condition  alike,  and  its  special  manifestations  in  different 
cases  are  as  multiform  as  the  human  faculties,  and  as  complex  as  different 
combinations  of  unusual  developments  of  those  faculties  can  make  it. 
There  are  certain  human  beings  characterized  through  life  by  striking 

17 


258  THE    INSANE    DIATHESIS. 

peculiarities,  eccentricities,  originalities  in  useless  ways,  oddities,  dispro- 
portionate developments,  and  nonconformities  to  rule,  these  things  not 
amounting  to  mental  disease  in  any  correct  sense,  and  yet  being  usually 
by  heredity  closely  allied  to  it,  or  by  evolution  ending  in  it  at  last.  The 
children  of  insane  parents,  or  some  of  the  members  of  families  who  have 
developed  many  neuroses,  are  most  apt  to  exhibit  the  symptoms  of  the 
insane  diathesis.  Its  symptoms  are  so  various  that  they  cannot  be  briefly 
described.  One  has  merely  to  read  the  works  of  the  modern  psycho- 
logical novelist  to  find  the  type  of  person  I  refer  to  in  abundance.  No 
one  has  lived  long  in  the  world  Avithout  meeting  in  the  flesh  many 
examples  of  it. 

And  there  have  been  enough  examples  of  it  in  the  real  lives  recorded 
in  biographies,  ranging  from  the  inspired  idiots  to  the  inspired  geniuses 
among  mankind.  We  may  safely  reckon  Chatterton,  De  Quincy,  Cowper, 
Turner,  Tasso,  Lamb,  and  Goldsmith,  to  take  a  few  men  of  genius,  as 
having  had  in  some  degree  the  insane  temperament.  We  find  some  such 
persons  strikingly  original,  but  not  reasonable ;  difierent  from  other  men 
in  their  motives,  in  their  likings,  in  their  ways  of  thinking  and  acting  to 
such  an  extent  that  human  society  would  at  once  come  to  an  end  were  all 
others  like  any  of  them.  They  are  all  in  the  highest  degree  "impracti- 
cable" and  "unwise"  in  the  conventional  senses  of  those  words.  Some 
are  abnormally  sensitive  and  receptive,  others  abnormally  reactive.  Some 
are  subject  to  influences  and  motives  that  are  absolutely  unfelt  by  ordi- 
nary men,  such  as  hypnotism,  sympathy  with  animals,  etc.  Most  of  the 
spiritualists,  thought-readers,  and  clairvoyants  who  are  honest,  as  well  as 
many  "Bohemians,"  are  of  this  class.  The  actions  of  most  of  them  may 
be  described  as  instinctive.  They  do  not  find  their  way  to  lunatic 
asylums,  but  their  friends  often  have  to  consult  our  profession  about 
them,  especially  in  youth.  And  fortunate  would  it  be  for  many  of  them 
if  the  doctor  had  the  direction  of  their  upbringing  on  physiological  and 
medico-psychological  principles,  instead  of  the  schoolmaster  on  doctrinaire 
and  purely  mental  ideas.  How  much  unhappiness  might  have  been  saved 
in  the  world  had  this  been  done  I  For  if  there  is  any  distinguishing 
feature  of  many  of  them,  it  is  the  capacity  to  be  miserable.  Nothing 
reconciles  one  so  to  the  abundance  of  commonplaceness  and  stupidity  in 
the  world  as  a  study  of  the  lives  of  some  of  these  persons.  And  surely 
our  profession  will  in  the  future  be  able  to  apply  its  knowledge  of  brain 
function  and  development  and  the  laws  of  heredity  towards  making  the 
most  of  such  lives,  strengthening  the  weak  points  without  forcing  down 
the  strong  ones,  saving  from  misery  and  ruin  without  depriving  humanity 
of  their  originality  and  intenseness.  I  have  one  case  in  the  asylum  that 
may  be  counted  as  of  the  insane  temperament.  F.  M.,  the  son  of  an 
eccentric  father,  who  could  not  get  on  as  a  student,  because  he  would 
insist  on  studying,  not  what  was  prescribed,  but  what  he  liked,  whose 
knowledge  is  prodigious  on  all  subjects — the  only  man  whom  I  ever  knew 
who  had  read  through  the  JE-nci/clopccdia  Britannica,  and  lived  —  but 
whose  common  sense  is  infinitesimal.  I  never  saw  any  man,  sane  or 
insane,  who  could  "make  such  a  fool  of  himself,"  in  an  ordinary  com- 
pany of  ladies  and  gentlemen.  He  has  most  original  ideas  as  to  the 
future  politics  of  Europe,  founded  on  a  profound  study  of  the  mental 


THE    INSANE    DIATHESIS.  259 

characteristics  and  capacities  of  the  races  who  inhabit  it.  Yet  he  will 
get  up  and  sing  "My  Pretty  Jane"  in  a  large  company,  out  of  tune  and 
out  of  time,  and  so  ridiculously  that  there  is  scarcely  a  dement  in  the 
asylum  who  will  not  laugh  at  him,  and  call  him  "daft."  He  is  totally 
unfitted  to  "get  on"  in  the  world  in  any  way.  I  presume  it  was  this 
that  drove  his  friends,  after  many  trials  elsewhere,  to  send  him  to  a 
lunatic  asylum,  as  the  only  place  fitted  to  receive  such  a  being. 

Do  not  suppose  for  a  moment  that  all  persons  of  the  insane  diathesis 
are  geniuses  or  talented.  Nothing  could  be  further  from  the  truth. 
Most  of  them  are,  on  the  contrary,  very  poor  creatures  indeed,  a  nuis- 
ance to  their  friends,  and  no  good  to  the  world  at  large. 

The  insane  diathesis  diifers  essentially  from  the  German  Primare 
Verruektheit.  The  latter  is  an  insanity  naturally  evolved  in  early  life 
from  the  original  constitution  of  a  brain  which  may  have  been  at  first 
without  peculiarity,  but  gradually,  inevitably,  and  without  any  other 
cause  than  its  own  natural  evolution,  an  unsound  state  of  mind  is  de- 
veloped without  preliminary  explosion  of  brain-storm  in  the  shape  of  an 
attack  of  mania  or  melancholia. 


LECTURE    X. 

GENERAL  PARALYSIS— PARALYTIC  INSANITY. 

General  Paralysis  is  not  only  a  variety  of  insanity,  but  a  true  cere- 
bral disease,  as  distinct  from  any  other  disease  as  smallpox  is  from  scar- 
latina. It  is  a  disease  of  extraordinary  interest  physiologically,  patho- 
logically, and  psychologically.  Its  study  has  somatized  and  definitized 
the  study  of  all  mental  diseases,  and  has  added,  and  will  add  still  more, 
to  our  knowledge  of  the  connection  of  mind  with  body,  and  of  mental 
and  motor  disturbances.  What  we  knew  of  its  symptoms  and  pathology 
ought  to  have  led  to  the  conclusion  that  the  cerebral  convolutions  have 
motor  functions  long  before  Hughlings  Jackson,  Hitzig,  and  Ferrier  ar- 
rived at  their  generalizations  on  the  subject.  Being  a  distinct  disease, 
clinically  and  pathologically,  it  can  be  defined,  and  I  should  give  its  defi- 
nition thus :  A  disease  of  the  cortical  part  of  the  brain,  characterized 
by  progression,  by  the  combined  presence  of  mental  and  motor  symptoms, 
the  former  always  including  mental  enfeeblement  and  mental  facility, 
and  often  delusions  of  grandeur  and  ideas  of  morbid  expansion  or  self- 
satisfaction  ;  the  motor  deficiencies  always  including  a  peculiar  defective 
articulation  of  words,  and  always  passing  through  the  stages  of  fibrillar 
convulsion,  incoordination,  paresis,  and  paralysis  ;  the  diseased  process 
spreading  to  the  whole  of  the  nerve  tissues  in  the  body ;  being  as  yet  in- 
curable, and  fatal  in  a  few  years. 

The  disease,  for  convenience  sake,  has  been  divided  into  three  stages, 
the  first  of  which  is  that  of  fibrillar  tremblings  and  slight  incoordination 
of  the  muscles  of  speech  and  facial  expression,  and  of  mental  exaltation 
with  excitement ;  the  second  that  of  muscular  incoordination  and  paresis 
with  mental  enfeeblement ;  and  the  third  that  of  advanced  paresis,  or  no 
power  of  progression,  almost  inarticulate  speech,  and  at  last  paralysis 
with  mental  extinction.  Those  stages  form  a  convenient  basis  for  the 
study  of  the  disease. 

Let  us  look  at  a  case  in  the  first  stage  of  the  disease. 

F.  Y.,  a  fine,  strong,  handsome  man  of  thirty-five,  without  any  known 
hereditary  predisposition  to  insanity,  who  had  enjoyed  good  health  up  to 
the  time  of  his  present  attack.  His  temperament  is  sanguine,  diathesis 
neuro-arthritic,  and  his  disposition  frank,  unsuspicious,  boastful,  and 
hasty.  He  always  had  a  high  opinion  of  himself,  and  showed  it ;  was 
of  an  imaginative  turn,  and  had  a  physiological  tendency  to  exaggera- 
tion. His  feeling  of  bien  Hre  was  always  above  the  average;  his  habits 
had  been  industrious,  and  at  times  he  had  worked  very  hard  indeed.  He 
had  not  been  dissipated  in  the  worse  sense,  but  he  had  lived  freely,  taking 
lots  of  alcoholic  stimulants  habitually,  eating  much,  sleeping  generally 
too  little,  and,  above  all,  exceeding  greatly  in  regard  to  sexual  intercourse, 


GENERAL    PARALYSIS.  261 

both  before  his  marriage  and  since — he  had  been  married  for  three  years. 
He  had  never  had  syphilis  that  I  could  make  out,  and  certainly  has  no 
evidence  of  the  disease  on  his  body.  For  a  few  months  his  friends  have 
noticed  that  he  "has  not  been  the  same."  Six  months  ago  he  was  "not 
in  good  spirits,"  and  complained  of  flying  pains  in  the  head:  then  he 
was  a  little  forgetful,  wanting  in  application  to  his  work,  restless,  doing 
some  "unaccountable  things"  in  business,  e.  g.,  forgetting  to  claim 
money  due  to  him.  He  was  irritable  at  home,  a  thing  unusual  with  him. 
A  month  ago  he  began  to  express  an  exaggerated  sense  of  well-being, 
saying  he  never  was  so  well  in  his  life,  that  his  strength  was  "something 
wonderful; "  he  could  not  settle  down  to  his  daily  work,  his  natural  high 
opinion  of  himself  was  more  openly  expressed  to  comparative  strangers, 
one  of  whom  remarked  after  seeing  him,  "  what  a  conceited  fool  that  man 
is."  This  state  went  on  without  any  other  absolute  signs  of  insanity, 
and  without  awakening  the  suspicions  of  his  friends  that  he  was  mentally 
Avrong — that  is  always  about  the  last  thing  thought  of — until  one  morning 
he  announced  to  his  wife  that  he  had  the  day  before  purchased  several 
hundred  pounds'  worth  of  silver  plate,  and  had  ordered  his  coat  of  arms, 
with  his  name  in  full  to  be  engraved  on  each  article.  He  added  that  he 
had  lots  of  money,  and  had  a  scheme  through  which  in  a  week  he  would 
be  worth  many  hundreds  of  thousands  of  pounds.  On  inquiry  it  was 
found  that  he  had  ordered  the  plate ;  but  the  jeweller,  being  a  man  of 
sense  and  principle,  having  noticed  some  little  thing  in  his  manner  that 
savored  of  morbidness,  had  not  taken  any  steps  to  execute  the  order  till 
he  made  some  inquiries.  Many  commencing  general  paralytics  are  not 
so  lucky  as  this.  I  knew  one  who  spent  XIOOO  that  had  taken  him  ten 
years  to  make  in  a  week  before  his  disease  was  discovered,  and  another 
who  spent  £1000  in  a  month.  F.  Y.'s  wife  found  that  he  had  been 
buying  a  quantity  of  perfectly  useless  things  in  addition  to  the  plate, 
some  of  them  in  duplicate.  He  had  in  his  pocket  four  gold  pencil-cases, 
which  he  said  he  was  to  give  away  as  presents  to  people  to  whom  he  was 
under  no  obligation,  and  did  not  know  very  well.  She  of  course  saw 
that  something  was  wrong,  and  he  was  got  oif  to  the  country.  The 
restlessness  by  night  and  day  increased ;  there  was  constant  talking, 
almost  complete  sleeplessness ;  the  boastfulness  became  in  three  or  four 
days  exaggerated  delusions.  He  said  he  could  lift  one  thousand  pounds, 
that  he  was  the  best  rider,  swimmer,  and  jumper  in  the  world ;  he 
wanted  to  buy  every  farmer's  horse  he  met  on  the  road,  never  offering 
less  than  £100  for  any  animal,  and  at  once  bidding  another  .£100  if  the 
first  offer  was  jocularly  refused.  He  wrote  quantities  of  letters  to  all  his 
friends,  to  all  the  noblemen  in  the  district,  and  to  the  Queen,  offering  his 
services  to  make  their  fortunes,  and  asking  them  to  dinner.  The  only 
visible  peculiarity  of  the  writing  was  the  omission  of  many  single  words. 
In  a  few  days  more  he  was  maniacal,  and  so  impatient  of  contradiction 
that  he  struck  his  wife,  though  through  all  this  he  was  in  many  respects 
facile  and  easily  managed.  He  therefore  had  to  be  brought  to  the  asylum 
a  week  ago.  When  he  saw  me  he  offered  to  buy  the  institution  for 
£100,000,  and,  on  my  saying  that  was  too  little,  offered  £200,000,  and 
soon  got  up  to  £1.000,000.  On  my  saying  that  we  could  not  want  it, 
he  said  he  would  build  another,  the  most  magnificent  in  the  world,  and 


262  GENERAL    PARALYSIS. 

endow  it  with  a  million  a  year,  and  appoint  me  physician-in-chief  with  a 
salary  of  .£10,000,  first  getting  the  Queen  to  create  me  a  baronet  and 
giving  me  a  splendid  uniform,  chiefly  made  of  gold  cloth.  He  has  been 
sleepless,  destructive  to  his  clothing,  not  cleanly  in  his  habits  or  modes 
of  eating,  in  constant  motion,  facile  in  most  respects,  but  irritable  and 
impulsively  violent  when  his  commands  were  not  instantly  obeyed,  or 
when  he  was  prevented  from  carrying  out  his  grand  schemes.  He 
expressed  no  surprise  at  being  brought  here  at  all,  and  no  resentment  at 
those  who  brought  him. 

Look  at  him  now.  He  came  into  the  room  with  a  quick  step.  His 
attitudes  and  gestures  follow  and  accentuate  his  speech.  He  talks  rather 
quickly,  and  has  the  least  slurring  towards  the  end  of  long  sentences  and 
in  articulating  long  and  difficult  words  with  many  oft-repeated  consonants. 
"Round  about  the  rugged  rock  the  ragged  rascal  ran"  was  got  through 
fairly  well  the  first  time,  but  at  the  second  attempt  the  "ragged  rascal" 
got  into  a  sort  of  inarticulate  slur.  This  is  accompanied  by  fibrillar 
twitching  in  the  small  muscles  of  the  lips  and  round  the  eyes,  as  if  a 
sudden  electric  current  had  set  these  quivering.  As  he  breaks  into  a 
smile  this  is  very  apt  to  happen.  His  tongue  quivers  in  lines  on  its 
surface,  single  strands  of  muscle  being  affected.  His  pupils  are  contracted, 
irregular  in  outline,  and  the  right  is  distinctly  larger  than  the  left,  the 
latter  being  quite  insensitive  to  light.  Sometimes  it  is  one  pupil  and 
sometimes  the  other  that  is  small  and  insensitive,  or  large  and  insensitive, 
in  different  cases.  The  expression  of  his  eyes  is  feverish  and  strange. 
His  skin  is  moist,  and  feels  hot.  His  temperature  is  99.6°,  this  rising  to 
over  100°  at  night;  his  pulse  is  full  and  hard.  He  cannot  rest  or  sit  still. 
There  is  clearly  an  abnormal  generation  of  energy  in  his  motor  batteries. 
When  we  test  his  common  sensation,  it  is  found  to  be  markedly  dimin- 
ished. His  sense  of  smell  is  weakened,  though  it  is  not,  as  Voisin  says, 
so  blunted  that  he  cannot  smell  pepper.  I  have  seen  only  a  few  cases 
where  smell  was  so  anaesthetic  as  this.  He  tastes,  though  a  little  imper- 
fectly ;  by  and  by  he  will  not  be  able  to  distinguish  a  solution  of  quinine 
from  milk.  Shown  a  lot  of  colored  wools,  he  could  not  tell  the  blue, 
calling  it  red.  His  patellar  tendon  reflex  is  very  acute,  and  also  the 
spinal  and  skin  reflexes.  You  noticed  how  easily  he  was  led  off  from 
one  subject  to  another ;  this  facility  is  one  of  the  most  characteristic 
of  all  the  symptoms  present  in  all  stages  of  the  disease.  But  he  is 
irritable  on  contradiction,  and  resents  thwarting,  especially  if  it  is  done 
suddenly  and  imperiously.  General  paralytics  at  this  stage  are  some- 
times most  dangerous  from  their  absolute  fearlessness  of  consequences. 
This  insane  boldness  gives  much  trouble.  An  ordinary  insane  patient, 
if  not  deliriously  maniacal,  will  usually  yield  to  the  show  of  force,  but  a 
general  paralytic  will  try  to  fight  and  resist  any  number  of  men.  When 
we  try  him  to  walk  along  a  board  of  the  floor,  he  does  so  sprightly  and 
well,  but  on  telling  him  suddenly  to  turn  round,  he  cannot  do  so 
sharply,  but  takes  a  circle,  and  that  waveringly. 

This  man  is  in  the  first  stage  of  his  disease.  He  will  steadily  grow 
worse,  losing  body-weight  rapidly,  his  speech  getting  worse,  more  tremu- 
lous, and  having  more  difficulty  in  articulating  long  words  and  sentences. 
His  motor  excitement  will  be  shown  probably  by  his  tearing  dozens  of 


GENERAL    PARALYSIS.  263 

suits  of  clothes  all  to  ribbons.  I  have  a  gentleman  who  tore  one  great- 
coat into  over  a  hundred  pieces,  saying — "I'm  g-g-going  to  put  it 
tog-g-ger  again  as  soon  as  I  g-g-get  to  Jeru-sh-lem.  I've  got  a  million 
coats  there."  His  walking  will  become  aiFected,  and  his  mental  power 
will  become  gradually  more  enfeebled.  He  will  believe  all  the  delusions 
of  his  fellow-patients.  A  general  paralytic  is  about  the  only  insane 
person,  except  a  congenital  imbecile,  who  cannot  see  that  some  of  his 
fellow-patients  in  an  asylum  are  insane.  Their  letters  are  usually 
characteristic.     Here  is  one : 

"The  .  .  . '  of  the  Millenium.  R.  E.  A.  When  I  reach  the  elect,  teleght.  office 
will  send  u  despatch  the  Times  Millenum  begins.     Yours  in  the  Holy  love  of 

God  and  the  Holy  Trinity,  Israel  Jesu  Christ." 

Here  is  another,  addressed  "Countess  of  Elgin  and  Durham,"  but 

really  to  the  Queen  : 

" House,  Eoyal  National  Lunatic  Asylum. 

"  My  Dear  Wife, — I  am  very  glad  to  say  that  I  am  up  to  the  mark  in  every 
particular,  and  hope  your  system  is  up  to  the  scratch.  Has  John  Brown  undergone 
any  form  of  cremation?  I  am  glad  to  .  .  .  him  adopting  my  style  of  shepherd 
checked  trousers.  I  hope  both  Queens  are  well,  with  Princess  Louise,  Princesa 
Beatrice  .  .  .  that  I  will  give  them  all  that  is  necessary  in  this  world  and  the  world 
to  come.     Compts.  to  darling  '  Eugene  ' — Your  aifct.  husband." 

The  nisus  generativus  is  usually  not  exalted  in  general  paralytics.  In 
fact,  impotence  is  the  rule  during  the  latter  end  of  the  first  stage,  and 
even  after.  I  have,  however,  known  cases  where  children  were  pro- 
created in  the  beginning  of  the  first  stage,  and  I  have  one  case  now  who 
was  impotent  for  over  a  year  in  the  first  stage,  but  whose  sexual  power 
returned  in  the  second  stage,  with  many  other  apparent  signs  of  improve- 
ment, and  his  wife  had  a  child  to  him,  begotten  then.  He  again  became 
impotent  in  the  end  of  the  second  stage.  I  have  known  more  than  one 
case  of  general  paralysis  who  was  a  masturbator  during  the  early  part  of 
the  first  stage. 

Let  us  now  see  a  typical  case  in  the  second  stage  of  the  disease. 

F.  X.,  now  forty-five,  a  clerk,  with  a  history  somewhat  resembling 
F.  Y.  He  became  affected  a  year  ago,  and  has  passed  through  a  first 
stage  of  exaltation  and  excitement,  which  for  the  past  two  months  has 
been  slowly  passing  off.  Mark  his  facial  expression,  or,  I  should  rather 
say,  his  want  of  facial  expression.  His  face  looks  fat,  heavy,  and  dull, 
as  if  the  expression  had  been  wiped  out  of  it,  and  this  even  when  he 
speaks.  There  are  no  movements  of  the  features  corresponding  with  the 
emotions  he  is  experiencing.  There  is  a  heavy  flabbiness  about  him. 
After  losing  over  two  stones  in  the  first  stage  of  the  disease,  he  has  now 
made  it  up  again  in  fat  if  not  in  muscle. 

There  is  a  contented  facile  hebetude  of  mind  in  him.  He  expresses  few 
wants,  says  he  is  quite  well,  and  that  he  can  walk,  work,  sing,  or  do 
business  as  well  as  he  ever  did,  none  of  which  is  true,  for  he  is  very 
shaky  on  his  legs,  cannot  walk  a  mile,  his  handwriting  is  tremulous,  and 
he  has  no  initiative  mental  power,  no  spontaneity,  and  no  power  of  voli- 

'  Where  words  are  omitted. 


264  GENERAL    PARALYSIS. 

tion.  He  does  not  now  obtrude  his  delusions,  but  when  asked  he  still 
says  in  a  silly  way  he  is  rich  and  strong,  but  hesitates  to  specify  the 
millions  he  is  worth,  until  pressed.  He  agrees  with  all  you  say,  and  is 
facile  and  easily  managed.  His  pupils  are  widely  dilated,  and  the  left 
more  so  than  the  right ;  his  pulse  is  68,  and  easily  compressible ;  his 
temperature  97°,  but  still  a  little  higher  at  night;  his  tendon  reflex  is 
dull ;  his  spinal  reflex  function  dull  too  ;  his  power  of  swallowing  a  little 
impaired.  His  speech  is  most  markedly  affected  now,  and  the  tone  of 
his  voice  is  quite  changed.  He  cannot  say  "  round  about  the  rugged 
rock  the  ragged  rascal  ran  "  at  all.  There  are  still  some  tremblings 
about  his  face  as  he  speaks,  but  they  consist  of  the  incoordination  of 
whole  groups  of  facial  and  articulatory  muscles.  He  is  very  kleptoma- 
niacal,  picking  up  and  stuffing  into  his  pockets  any  bit  of  trash  he  can 
lay  hands  on.  The  dorsum  of  his  tongue  presents  a  general  undulatory 
surface  when  put  out.  He  cannot  turn  round  quickly  without  risk  of 
falling ;  he  straddles  a  little  in  walking,  is  apt  to  stumble  over  small 
obstacles,  and  the  effort  of  a  long  walk  so  exhausts  the  energizing  power 
of  his  motor  batteries  that  he  gets  almost  paralyzed,  and  is  then  unable 
to  walk  at  all.  There  is  no  vigor  in  any  muscular  movement  he  per- 
forms. His  urine  often  dribbles  away.  Occasionally  he  is  noisy  at  night 
in  an  automatic,  causeless  way.  He  will  become  weaker  steadily.  His 
.speech  will  soon  become  less  articulate,  until  he  reaches  the  third  stage, 
which  this  next  patient  has  reached. 

r.  W.,  aet.  40.  Has  had  general  paralysis  for  two  years,  and  has 
passed  through  the  first  and  second  stages.  He  is  now  so  paralyzed  that 
he  cannot  walk  or  even  stand  steadily.  He  cannot  write,  and  his  mental 
state  is  that  of  a  happy  lethargy.  When  asked  if  he  has  *a  million  of 
money  his  facial  muscles  begin  to  act  in  an  incoordinated  way,  his  eye- 
lids half  shutting,  his  mouth  being  drawn  out,  the  lips  moving  spasmodi- 
cally like  a  patient  going  into  an  epileptic  fit,  the  whole  effect  being  that 
of  a  contorted  imitation  of  a  smile,  accompanied  by  a  slow,  prolonged,  and 
jerky  "Y-a-a-a" — which  is  all  that  he  can  articulate  for  "Yes."  But 
he  looks  as  if  his  subjective  condition  was  one  of  perfect  happiness.  He 
asks  for  nothing,  he  complains  of  nothing ;  he  is  noisy  at  night  often,  but 
it  is  in  an  automatic  way.  He  needs  to  sleep  on  a  mattress  on  the  floor 
in  a  room  specially  warmed  by  hot  air,  for  he  rolls  about  the  room  at 
night.  He  is  quite  unable  to  retain  his  urine  and  feces  by  night  or  day. 
All  his  food  has  to  be  liquid  or  minced,  for  he  would  bolt  it  in  solid 
masses  and  choke.  He  is  greedy  for  his  food  when  it  is  put  into  his 
mouth,  though  he  is  unable  to  feed  himself  This  man  had  two  "conges- 
tive attacks"  to  which  most  general  paralytics  are  subject.  One 
occurred  about  the  end  of  the  first  stage  of  the  disease,  and  was  accom- 
panied by  unconsciousness,  a  temperature  of  103°,  general  convulsions 
which  began  and  ended  on  the  right  side,  but  affected  the  whole  body  in 
the  middle  of  the  attack.  They  lasted  for  about  four  hours,  and  were 
succeeded  by  stupor,  which  lasted  for  foi'ty-eight  hours.  He  had  reten- 
tion of  urine  during  that  time,  as  he  slowly  recovered  consciousness  ;  after 
that  it  was  found  that  his  speech  and  his  walking  were  more  paretic,  and 
his  mental  power  more  enfeebled.  Congestive  attacks  always  leave  the 
patients  worse  in  these  respects.     The  second  attack  was  of  the  same 


GENEKAL    PARALYSIS.  265 

character,  but  less  severe,  and  occurred  in  the  second  stage.  Soon  after 
it  a  fellow-patient  struck  him  on  the  side  of  the  head,  and  the  ear  of 
that  side  began  to  swell  in  the  centre  of  the  helix,  this  swelling  slowly 
increasing  in  size  until  the  ear  was  painted  with  blistering  fluid,  as  rec- 
ommended by  Dr.  Hearder,  when  it  ceased  to  increase  in  size,  and 
slowly  shrank  up,  leaving  that  part  of  the  ear  hard  and  slightly  shrivelled. 
If  it  had  not  been  blistered,  the  swelling  would  have  increased  until  the 
whole  ear  would  have  looked  like  a  bluish  egg  attached  to  the  side  of 
the  head.  This  would  have  been  found  to  consist  of  a  bloody  gelatinous 
material  if  it  had  been  opened  (but  this  should  not  be  done),  separating 
the  outside  skin  of  the  ear  from  the  cartilage.  In  time  it  would  have 
shrunk  up,  leaving  the  outside  ear  a  hard,  shrivelled,  cartilaginous-looking, 
ill-shapen  mass.  This  is  the  "  insane  ear,"  or  Ticematoma  auris,  which  is 
very  common  in  general  paralysis,  and  is  sometimes  seen  in  bad  cases  of 
mania  of  the  chronic  variety,  sometimes  in  chronic  epileptics,  and  occa- 
sionally in  agitated  and  convulsive  melancholia,  and  rarely  in  dementia. 
Its  occurrence  is  always  a  bad  sign  for  prognosis  in  any  case  of  insanity. 
I  have  seen  only  three  cases  recover  out  of  over  eighty  cases  who 
had  hcematoma  auris.  It  is  connected  with  arterial  degeneration  in  the 
branches  of  the  carotid  artery.  The  gelatinous  bloody  contents  of  a 
haematoma  are  like  the  extravasations  under  the  dura  mater  in  pachyme- 
ningitis hcemorrliagica  interna^  a  disease  that  is  liable  to  occur  in  precisely 
the  same  class  of  cases.  Hcematoma  auris  has  been  found  in  persons 
sane  in  mind,  though  very  rarely.  The  exciting  cause  is  often  severe 
violence  to  the  ear,  but  this  is  not  necessary,  and  no  violence  will  cause 
such  a  condition  of  the  ear  where  the  morbid  arterial  conditions  for 
its  formation  do  not  exist.  Blistering,  if  applied  in  time,  usually  stops 
further  growth,  but  I  have  met  with  cases  where  it  began  to  grow  after 
being  stopped,  was  again  blistered,  again  ceased  to  grow,  then  again 
enlarged,  and  finally  swelled  up  to  the  size  of  an  egg  in  spite  of  blistering. 

F.  Ws.  common  sensibility  is  much  impaired,  so  that  you  can  stick 
pins  into  him  without  his  feeling  it.  The  reflex  action  of  his  cord 
is  over-acute,  and  extends  upwards  from  the  section  of  cord  irritated,  for 
if  you  tickle  one  foot  they  are  both  drawn  up  with  a  jerk,  and  the  two 
hands  and  the  chest  muscles  are  contracted  likewise.  The  impression 
travels  upwards  more  readily  than  downwards. 

He  will  soon  become  so  paralyzed  that  voluntary  motion  in  the  legs  of 
any  kind  will  cease.  He  will  have  to  be  placed  on  a  water  mattress,  and 
his  trophic  power  will  become  so  affected  that  his  urine  Avill  irritate  his 
skin  and  bed-sores  will  tend  to  form,  and  he  will  die  of  exhaustion 
probably  within  six  months  from  this  time,  or  within  three  years  from  the 
beginning  of  his  disease. 

Variations  prom  the  Typical  Form. — The  usual  course  of  this 
disease  is  well  illustrated  by  these  three  patients,  but  a  large  number  of 
the  cases  do  not  follow  the  typical  course.  For  the  diagnosis  of  those 
exceptional  cases  we  require  first  to  know  clinically  the  varieties  that  are 
found,  to  understand  and  take  into  account  the  true  pathological  nature 
of  the  disease,  and  to  be  able  to  separate  the  essential  from  the  non- 
essential features  of  it.  I  shall  instance  a  few  varieties  of  the  disease. 
The  chief  of  these  is  where  the  pathological  process  does  not  begin  in 


266  GENERAL    PARALYSIS. 

the  cortex  of  the  brain,  but  in  the  cord  (the  tabic  form)  or  in  the  neurine 
portions  of  the  organs  of  special  sense  (the  sensory  form),  or  in  a 
peripheral  nerve  (the  peripheral  form),  spreading  upwards  by  a  patho- 
logical propagation  along  the  connecting  nerves  in  the  lines  of  physiological 
fiinction,  till  it  reaches  the  brain  cortex.  These  varieties  are  rare,  but 
distinct  enough  when  they  occur,  and  very  interesting.  They  would 
seem  to  imply  that  the  pathological  process  of  general  paralysis  is  essen- 
tially the  same  as  the  progressive  Wallerian  atrophy  of  the  nerve  trunks, 
or  the  degeneration  of  the  posterior  columns  of  the  cord  in  locomotor 
ataxia.  I  am  not  quite  prepared  to  accept  this  conclusion,  for  there  are 
as  yet  many  pathological  differences  between  the  appearances  of  both  of 
these  and  the  brain  cortex  as  affected  by  general  paralysis.  The  essen- 
tial structure  and  the  functions  of  the  brain  cortex  are  so  different  from 
any  other  portion  of  the  nervous  system  that  it  is  quite  possible  to 
suppose  a  diseased  process  of  one  pathological  nature  slowly  advancing 
along  a  peripheral  nerve  or  along  the  cord,  and  when  it  reaches  the 
totally  different  and  higher  structure  of  the  brain  cortex,  that  it  should 
assume  a  different  nature,  just  as  the  process  of  gelatinous  swelling  of 
the  synovial  membrane  of  a  joint  when  it  reaches  the  cartilage,  changes 
its  pathological  form,  and  becomes  ulceration.  And  then  it  must  be 
remembered  that  in  those  rare  cases  of  what  appear  to  be  pathological 
propagation,  there  may  have  been  the  ordinary  causes  of  general  paralysis 
operating  in  regard  to  the  cortex,  and  the  peripheral  disease  may  have 
been  merely  an  extra  cause  at  work.  To  show  what  I  mean  I  shall  refer 
to  a  few  cases. 

G.  A.,  a  man  of  50,  who  had  been  affected  with  ordinary  typical 
locomotor  ataxia  for  seven  years,  began  to  be  maniacal  and  sleepless,  and 
to  have  delusions  of  grandeur,  affirming  he  was  an  earl  and  possessed 
millions  of  money,  and  that  he  could  ride,  run,  and  swim  better  than  any 
man  in  the  world.  He  used  to  write  about  fifty  letters  a  day,  ordering 
every  sort  of  thing  imaginable,  asking  the  Queen,  the  House  of  Lords, 
and  the  Cabinet  to  dinner,  etc.  His  speech  was  markedly  affected  by 
the  characteristic  tremble  of  the  lips,  the  shuffle  and  thickness  in  the 
articulation  of  long  words  and  sentences.  He  passed  through  the  second 
and  third  stages  of  the  disease,  and  died  in  eighteen  months  from  the 
time  of  the  beginning  of  the  mental  symptoms.  There  was  no  post- 
mortem examination  in  that  case,  but  I  have  examined  the  brain  and 
cord  in  other  similar  cases,  and  have  found  that  the  spinal  disease  could 
be  traced  up  through  the  medulla  and  the  lower  ganglia  into  the  brain 
cortex.  I  have  always  found  in  those  tabic  cases  that  the  peculiar 
adhesion  of  the  pia  mater  to  the  convolutions  (see  Plate  I.,  Frontispiece) 
was  more  marked  at  the  base  of  the  brain  and  in  the  cerebellum  instead 
of  over  the  vertex,  as  in  the  typical  case  of  general  paralysis.  In  one 
such  case,  who  died  at  Morningside  Asylum,  my  late  assistant.  Dr.  J. 
J.  Brown,  found  the  cord  degenerated,  not  only  in  its  posterior  columns, 
but  most  markedly  also  in  the  anterior  columns.  In  that  case  the  medulla 
oblongata  was  more  diseased  than  I  ever  saw  in  any  other  case  of  any 
kind.     Not  a  single  nerve  fibre  or  cell  seemed  to  be  normal. 

The  next  case  is  the  most  typical  of  six  cases  I  have  met  with,  where- 


GENERAL    PARALYSIS.  267 

there  was  first  disease  of  the  retina,  and  then,  after  some  years,  general 
paralysis. 

G.  B.,  having  exposed  his  head  to  a  hot  sun  while  bathing,  had 
hemorrhage  into  the  retina,  causing  complete  blindness.  After  a  few 
years  he  fell  into  general  paralysis,  and  Avhen  he  died  I  found  that  the 
optic  nerves  were  hard  gray  cords,  with  no  nerve  substance  left,  that  the 
optic  tracts  were  in  the  same  condition,  and  the  gray  sclerotic  degenera- 
tion could  be  traced  backwards  to  the  corpora  quadrigemina,  the  pos- 
terior of  which  were  gray  and  sclerotic.  The  evidences  of  cortical 
disease  were  strongest  at  the  base  of  the  brain,  the  convolutions  of  the 
anterior  lobes  over  the  orbital  plates  being  especially  affected,  the  pia 
mater  being  universally  adherent  there. 

I  knew  a  gentleman  who  became  stone  deaf  in  one  ear  several  years 
before  he  developed  general  paralysis,  and  though  I  had  no  pathological 
proof  that  the  case  was  one  of  propagation,  I  had  no  doubt  in  my  own 
mind  on  the  subject.  He  was  a  medical  man,  and  his  deafness  was  of  a 
peculiar  character,  so  that  it  alarmed  him  very  much ;  and  when  the 
first  symptoms  of  general  brain  disease  appeared,  he  said  he  thought  it 
was  just  the  extension  of  the  disease  from  his  internal  ear.  Professor 
Laycock  used  to  quote  a  case  of  his  where  the  disease  had  spread  upwards 
from  a  Wallerian  atrophy  of  one  of  the  motor  nerves  of  one  of  the 
fingers.  I  had  a  case,  G.  D.,  a  woman  of  thirty-six,  who  passed  gradu- 
ally into  an  attack  of  quiet,  non-delusional  general  paralysis  after  a  small 
punctured  wound  in  the  top  of  her  head  penetrating  for  about  half  an 
inch  into  the  brain.  A  pitchfork  had  fallen  accidentally  on  the  top  of  her 
head,  as  she  was  loading  a  cart  of  wheat.  After  death  the  whole  of  the 
convolutions  round  the  wound  were  found  specially  afiected,  though  the 
cortex  in  most  parts  of  the  vertex  and  sides  of  the  brain  were  affected 
as  well. 

There  are  many  cases  of  general  paralysis  where  the  course,  and  even 
the  nature,  of  the  symptoms  vary,  within  limits,  very  much  from  the 
typical  symptoms  and  the  typical  course.  They  constitute"  symptomato- 
logical  varieties  of  the  disease.  The  most  common  and  the  most  marked 
of  these  is  the  non-delusional  variety,  as  seen  in  the  following  case, 
where  there  was  no  excitement,  no  delusions  of  grandeur,  and  no  conges- 
tive attacks,  but  simply  a  gradual  mental  enfeeblement  beginning  with 
the  volitional  power,  and  a  gradual  paresis  beginning  with  muscular 
weakness  and  fibrillar  tremblings  in  the  facial  muscles  and  tongue,  this 
gradually  passing  into  complete  incoordination. 

0.  C,  aet.  50.  A  quiet-living  man,  who  had  married  about  three 
years  before  he  became  affected  in  mind,  first  showed  mental  defect  by 
irresolution,  want  of  a  keen  interest  in  anything,  forgetfiilness,  and  the 
want  of  a  realizing  sense  of  the  necessity  of  his  working  in  order  to  live. 
Soon  he  got  a  little  irritable  Avhen  pressed  to  work.  Then  his  mind 
showed  clears  signs  of  enfeeblement  and  facility.  He  would  believe 
silly  things,  he  could  not  carry  on  a  connected  conversation,  he  had  few 
likes  or  dislikes.  I  saw  him  at  this  stage,  and  found  his  speech  thick, 
his  lips  showing,  as  he  began  to  speak,  that  fatal  quiver  which  to  a 
practised  eye  almost  marks  the  disease  from  all  others.  His  \valk,  too, 
was  not  firm,  and  in  turning  round  sharply  he  did  so  uncertainly.     He 


268  GENERAL    PARALYSIS. 

gradually  got  more  enfeebled  and  frail  in  mind,  his  speech  became  less 
articulate,  and  his  Avalk  more  paretic.  Nearly  all  his  symptoms  were 
negative.  About  the  only  positive  mental  symptom  he  had  was  a  gentle 
kleptomania.  He  would  pick  up  and  fill  his  pockets  with  stray  pocket- 
handkerchiefs,  aprons,  and  rags  in  a  sort  of  automatic  way,  not  in  the 
least  caring  or  objecting  Avhen  they  were  taken  from  him.  He  died  in 
six  years,  absolutely  paralyzed,  of  pure  exhaustion,  never  having  made 
a  sound  that  could  be  called  articulate  for  a  year,  or  voluntarily  moved 
a  voluntary  muscle  during  that  time,  lying  on  a  water-bed,  and  leading 
a  merely  vegetative  life.  Such  cases  are  apt  to  live  a  long  time.  They 
are  not  usually  caused  by  a  dissipated  or  excited  life,  and  their  subjects 
were  originally  of  a  calm,  phlegmatic  temperament.  Nearly  one-third 
of  all  the  cases  of  the  disease  that  I  have  seen  were  of  this  character. 
This  type  is  very  common  in  the  female  sex ;  in  fact,  the  majority  of 
female  cases  conform  to  it  more  or  less.  It  is  also  the  common  type  of 
the  disease  in  those  parts  of  the  country  where  the  people  live  unex- 
citing lives. 

Standing  at  the  opposite  point  from  this  quiet  form  of  the  disease  are 
the  two  varieties  of  which  I  shall  now  give  examples.  The  first  is  the 
specially  convulsive  form,  as  exhibited  in  the  following  three  cases: 

G.  E.,  aet.  about  40.  A  man  who  had  been  of  an  excitable  disposi- 
tion, and  had  led  a  dissipated  life  in  regard  to  drink  and  women,  of  a 
fiery  temper;  who  had  sufiered  from  syphilis,  whose  whole  life  had  been 
a  whirl  of  mental  excitement.  He  had  complained  for  some  time  of  very 
severe  headaches,  had  been  ofi"  his  sleep,  had  been  unusually  irritable  and 
not  fit  to  do  a  day's  business.  One  day  he  suddenly  fell  down  in  a  fit, 
and  remained  in  general  and  severe  convulsions  with  complete  stupor  for 
about  two  hours  and  died  in  them.  After  death,  I  found  all  the  patho- 
logical signs  of  general  paralysis;  especially  the  adherence  of  the  pia 
mater  to  the  convolutions  of  the  vertex  in  patches  was  most  marked. 
There  was  no  local  disease  in  the  membranes  or  vessels  that  has  been 
recognized  as  syphilitic,  and  he  had  not  been  drinking  heavily  before  his 
death. 

My  conclusion  was  that  it  was  a  case  of  general  paralysis,  with  a 
strongly  convulsive  tendency,  this  killing  the  patient  before  the  usual 
symptoms  had  time  to  develop.  I  do  not  know  whether  I  should  or  not 
have  been  able  to  diagnose  the  case  had  I  seen  him  before  the  convulsive 
attack,  or  whether  there  were  any  motor  symptoms  present  before  it 
occurred.  But,  it  may  be  said — Is  it  possible  for  a  man  to  have  marked 
disease  of  the  brain  affecting  the  convolutions  of  the  vertex,  without 
mental  or  motor  symptoms?  My  experience  of  general  paralysis  would 
lead  me  to  the  conclusion  that  the  recognizable  pathological  lesions  of  the 
convolutions  precede  the  mental  symptoms.  They  usually  need  to  develop 
in  some  intensity,  and  to  involve  a  certain  number  or  kind  of  eoni'olutions, 
before  mental  or  motor  symptoms  become  very  manifest. 

I  had  a  general  paralytic  in  the  asylum,  G.  A.,  who  took  an  epilepti- 
form convulsion  every  day  for  months.  The  temperature  rises  often 
before,  and  always  after,  an  epileptiform  convulsion  or  a  mere  congestive 
attack  in  these  cases.  I  had  another  patient  who  had  many  epileptic- 
looking  fits  for  a  year,  and  who  was  treated  for  epilepsy  by  eminent  physi- 


GENERAL    PARALYSIS.  269 

cians  during  that  time,  before  the  usual  mental  and  motor  signs  of  general 
paralysis  appeared. 

The  next  marked  departure  from  the  normal  type  of  general  paralysis, 
such  as  I  have  described  it,  is  where  the  first  stage  consists  of  maniacal 
exaltation  alone,  without  any  motor  sign  that  one  can  recognize,  for 
months,  and  even  years.  I  have  had  several  cases  now  who  had  what 
appeared  to  be  attacks  of  ordinary  acute  mania,  and  to  all  appearance 
had  recovered,  who  had  even  second  attacks  and  recovered,  and  then 
developed  the  motor  symptoms  of  general  paralysis.  The  following  is 
one  of  them : 

G.  G.,  get.  36,  an  Irishman  born  (Irishmen  often  enough  suffer  from 
general  paralysis  here  if  they  do  not  at  home),  drunken  and  hard  work- 
ing; married.  Had  an  attack  of  "acute  mania"  in  1876,  and  was  sent 
to  the  asylum,  and  "recovered"  in  five  weeks.  No  motor  signs  or 
evidences  of  general  paralysis  were  noted  by  me  or  anyone  else  here.  In 
1878,  he  had  another  attack,  and  this  time  some  suspicion  of  the  disease 
was  excited,  but  no  diagnosis  made.  He  was  again  discharged  recovered, 
and  it  was  only  on  his  third  admission,  three  years  after  his  first,  that  the 
disease  was  manifest.  He  died  of  it  in  three  years.  I  lately  saw  a  case 
with  Dr.  Bramwell,  in  which  I  had  no  doubt  whatever  as  to  the  nature 
of  the  disease,  and  have  none  now,  in  which  the  symptoms  were  those  of 
the  second  stage,  with  indistinct  articulation,  diflBcult  walking,  great 
mental  facility,  epileptiform  convulsions,  and  bed-sores,  and  yet  he  has 
so  far  improved  that  he  has  gone  to  work  as  a  draughtsman,  and  is  said 
to  be  doing  his  work  well. 

In  such  a  case  as  that  of  G.  G.,  I  have  no  doubt  whatever  that  the 
first  attack  in  1876  was  really  a  part  of  the  general  pai'alysis,  but  at  that 
time  the  disease  was  probably  superficial  in  the  cortex  and  confined  to  a 
limited  area,  and  did  not  involve  to  any  extent  the  motor  centres  in  the 
convulsions,  causing,  no  doubt,  much  congestion  and  much  vesicular 
overactivity  in  the  cortex,  but  not  incoordination  of  motion.  The  first 
attacks  were  brain  storms  that  passed  away,  so  far  as  the  active  congestion 
and  the  vascular  disturbance  were  concerned,  leaving  the  incipient  organic 
convolutional  change  there,  but  quiescent.  I  have  also  no  doubt — in  fact, 
I  obtained  clear  evidences  of  it  from  his  wife — that  intellectually  he  was 
weakened  after  the  first  attack  of  "acute  mania"  in  1876.  Such  cases 
enable  one  to  understand  the  "recoveries"  and  "cures"  of  general  paral- 
ysis, not  one  of  which,  I  believe,  was  ever  real  or  lasting. 

It  is  common  to  have  in  the  beginning  of  the  first  stage  very  acutely 
maniacal  mental  symptoms,  and  no  motor  signs  to  be  discovered,  and 
general  paralysis  should  never  be  diagnosed  from  mental  symptoms  alone. 
I  had  a  case,  G.  H.,  who  was  most  acutely  maniacal,  very  dangerous,  very 
homicidal,  very  impulsive,  and  very  strong  willed  and  unmanageable  for 
twelve  months  before  there  were  any  motor  symptoms  that  enabled  me  to 
diagnose  general  paralysis.  From  the  state  of  his  pupils,  and  the  looks 
and  expression  of  his  face,  I  suspected  it,  but  I  could  not  have  said 
definitely  it  was  any  other  condition  than  acute  mania  for  the  first  twelve 
months.  It  is  very  uncommon  for  a  man  who  suffers  from  general 
paralysis  to  have  been  insane  before,  but  I  have  met  with  a  few  examples. 
One,  G.  H.  A.,  had  an  attack  of  mania  in  youth,  recovered,  kept  well, 


270  GENERAL    PARALYSIS. 

and  did  his  ordinary  business  for  twenty  years,  and  at  the  age  of  forty- 
four  became  a  general  paralytic. 

We  have  certain  long-lived  cases  that  do  not  die  at  the  normal  time, 
but  live  on  for  periods  up  to  twenty-two  years.  I  have  now  under  my 
care  such  a  patient. 

G.  J.,  set.  35,  admitted  to  the  Royal  Edinburgh  Asylum  18th  Novem- 
ber, 1860,  Had  led  a  somewhat  rough  life,  and  nine  months  before  had 
an  "epileptic  fit,"  No  heredity  to  insanity,  but  he  had  a  very  eccentric, 
somewhat  silly  sister.  The  attack  had  been  preceded  by  a  melancholic 
condition,  and  he  had  refused  his  food.  His  articulation  was  slurred,  his 
pupils  unequal,  his  walk  slow  and  unsteady.  He  was  unhesitatingly 
diagnosed  as  a  general  paralytic.  After  nine  months  he  was  taken  out 
of  the  asylum  by  his  relatives,  but  had  to  be  sent  back  again  in  eighteen 
months,  having  been,  while  outside,  totally  unable  to  do  anything  for  his 
own  livelihood,  and  having  got  gradually  worse  in  mind  and  body.  When 
admitted  in  1863,  he  was  "stout,  stupid,  and  silent,"  had  the  "peculiar 
expression  of  face  of  general  paralysis  well  marked,  as  well  as  its  walk," 
Some  days  he  was  "quite  well  and  happy,"  In  a  few  months,  he  was 
"uproariously  happy,"  with  the  most  exaggerated  notions  about  his 
riches,  strength,  height,  beauty,  etc.  He  is  forty  feet  high,  is  God,  is 
married  to  the  Queen,  is  the  strongest  man  in  the  world,  and  has  a 
"damnable  heap  of  money."  All  Leith  Docks  belonged  to  him,  and 
most  of  the  ships  there.  In  December,  1863,  he  had  a  series  of  epilepti- 
form fits,  which  were  ushered  in  by  a  regular  congestive  attack.  He 
became  very  weak,  and  could  with  difficulty  articulate,  or  make  his  water. 
He  got  over  this  condition  in  a  few  weeks,  and  became  facile  and  con- 
tented. An  assistant  physician  of  the  asylum  recorded  in  the  Case-book 
in  1864 — "Is  a  magnificent  specimen  of  a  general  paralytic."  In  June, 
1864,  he  had  a  congestive  attack,  succeeded  by  epileptiform  fits,  being 
maniacal  and  restless  afterwards.  In  August,  1864,  he  had  another 
congestive  attack,  and  one  in  January,  1865,  and  got  so  frail  in  March 
that  he  had  to  be  kept  in  bed.  In  March  he  had  another  congestive 
attack.  He  had  no  congestive  or  epileptiform  attack  again  till  December, 
1880.  During  all  these  years  the  symptoms  remained  the  same,  but  the 
disease  did  not  advance  much  till  after  the  epileptiform  attack  in  1880. 
The  period  of  general  convulsion  was  short,  only  a  few  minutes,  but  he 
was  confused  and  stupid  afterwards  for  four  hours,  and  was  then  excited 
and  noisy.  The  paresis  increased  after  this,  and  the  general  strength 
failed  much.  In  February,  1881,  he  had  another  severe  attack  of  gen- 
eral convulsions,  with  several  hours  of  stupor  following  them,  the  tem- 
perature rising  to  102.4°  in  three  hours,  and  then  falling  to  normal  in 
two  hours  after  that.  He  had  two  such  attacks  in  April  of  that  year. 
After  the  last  the  left  side  was  found  weaker  than  the  right,  and  he  was 
shaken  generally.  During  the  summer  he  could  not  walk  far  without 
becoming  paralyzed  in  his  legs ;  he  had  incontinence  of  urine,  his  speech 
was  thicker  and  less  articulate,  and  mentally  he  was  more  facile  and 
stupid. 

At  present  (November,  1882)  twenty-three  years  after  the  commence- 
ment of  his  illness,  his  condition  is  as  follows :  Facial  expression  vacant ; 
pupils  both  contracted,  but  partly  sensitive  to  light,  the  left  being  slightly 


GENERAL    PARALYSIS.  271 

the  larger,  outlines  not  regularly  circular ;  tongue  tremulous,  and  its 
muscles  incoordinated  over  surface;  articulation  affected  just  like  that  of 
a  typical  general  paralytic  at  the  end  of  the  second  stage  of  the  disease, 
difficult  words  being  worst  pronounced,  and  the  ends  of  sentences  worse 
than  their  beginning;  walk  uncertain,  dragging,  straddling;  sensibility 
diminished,  can  smell  pepper,  but  cannot  be  made  to  sneeze ;  spinal  reflexes 
very  acute,  patellar  tendon  reflex  quite  absent.  Often  has  retention  of 
urine.  Begins  a  walk  pretty  well,  but  soon  fails,  and  cannot  progress  at 
all ;  turns  round  with  difficulty ;  cannot  stand  on  one  leg ;  whole  nutrition 
flabby ;  mentally  in  a  flicile,  morbidly  contented,  exalted  state. 

It  may  be  said  that,  as  he  has  not  died,  it  is  impossible  to  say  that  this 
is  a  case  of  true  general  paralysis.  If  he  is  not,  he  has  had  every 
symptom  of  the  disease  except  its  termination  in  death,  and  neither 
Dr.  Skae  nor  I,  nor  one  of  the  score  of  assistant  physicians  here  who 
have  had  charge  of  him,  has  had  any  doubt  on  the  subject. 

The  common  age  for  the  occurrence  of  the  disease  is  between  twenty- 
five  and  fifty.  The  chart  in  Plate  VI.  shows  its  prevalence  in  one 
hundred  and  four  cases  admitted  to  this  asylum  as  compared  with  mania 
and  melancholia,  and  the  ages  at  which  it  occurred.  The  greatest 
number  of  cases  occurred  between  forty  and  forty-five  years.  But  there 
are  a  few  exceptional  patients.  We  have  had  at  Morningside  two  cases 
under  twenty,  one  at  sixteen,  and  the  other  at  twelve,  accounts  of  both  of 
which  were  published,  one  by  Dr.  Turnbull,  and  one  by  myself.  The 
diagnosis  in  both  being  confirmed  by  a  post-mortem  examination,  there 
could  be  no  doubt  as  to  the  nature  of  the  disease. 

Instead  of  the  exalted  condition  of  mind,  or  the  merely  enfeebled  and 
facile  one,  we  have  a  few  cases  (from  three  to  four  per  cent,  in  my  expe- 
rience) with  melancholic  symptoms.  My  belief  and  experience  is  that  in 
all  these  there  is  some  organic  visceral  disease  which  transmits  to  the  con- 
volutions sensations  that  are  disagreeable  and  depressing.  On  examina- 
tion of  our  pathological  register,  I  found  that  nearly  all  the  cases  of  the 
disease  that  had  tubercular  disease  or  broncho-pneumonia  had  been 
melancholic.  I  had  a  man,  G,  K.,  who  had  the  fixed  melancholic 
delusion  that  a  man  was  inside  him  who  annoyed  him  constantly,  and 
made  him  really  depressed,  and  after  death  we  found  tubercular  disease 
of  the  intestines.  I  have  a  most  instructive  case  now  showing  the 
influence  of  visceral  disease  on  the  mental  condition  of  a  general 
paralytic,  G.  L.,  a  cabman,  who  thought  on  admission  he  had  £30,000, 
and  got  .£1000  from  Queen  Victoria  for  driving  her  along  Princes  Street. 
Suddenly  one  day  he  became  melancholic,  saying  he  was  a  beggar,  and 
crying  bitterly.  We  examined  his  chest  and  found  he  had  bronchitis. 
The  reflex  action  was  so  dulled,  as  in  most  cases  of  the  disease,  that  he 
had  no  cough,  felt  no  pain,  and  made  no  complaint.  As  his  bronchitis 
improved,  his  mental  elevation  and  delusions  of  grandeur  returned.  He 
had  a  relapse,  and  the  melancholic  state  at  once  came  back.  For  a  week 
or  so  he  was  elevated  one  day  and  depressed  the  next.  At  last  the 
bronchitis  was  recovered  from,  and  he  is  the  happy  imaginary  possessor 
of  his  thousands.  Whenever  I  see  a  general  paralytic  dull  now,  I  always 
search  for  an  organic  visceral  cause,  and  usually  find  it. 

I  had  one  case  of  the  disease,  G.  M.,  that  began  with  aphasia,  and  was 


272  GENERAL    PARALYSIS, 

treated  for  several  months  for  this.  As  he  began  to  speak,  the  peculiar 
articulation  was  noticed,  and  he  died  in  about  two  years.  In  his  case, 
the  motor  reflex  excitability  of  the  brain  and  cord  was  greater  than 
I  ever  saw  in  any  case  whatever.  A  very  slight  tap  on  the  toe  would  set 
up  a  convulsion  first  in  that  leg,  and  then  in  the  next ;  a  slight  puff 
suddenly  into  his  face  would  make  him  jump  off  his  seat  with  his  whole 
body.  I  have  many  times  seen  general  paralytics  aphasic  after  conges- 
tive attacks.  In  such  cases,  and  in  all  cases  where  the  speech  was 
specially  affected  during  the  disease,  I  have  always  found  after  death 
that  the  third  frontal  convolution  of  the  left  side  and  that  region  of  the 
brain  had  the  pia  mater  especially  adherent  to  the  cortex. 

I  have  only  seen  one  patient  in  which  long-continued  ordinary  insanity 
became  changed  into  general  paralysis.  It  was  a  case  of  dementia  of 
twelve  years'  standing.  It  was  an  exception  that  proves  the  rule  that 
general  paralysis  and  ordinary  insanity  have  nothing  in  common  patho- 
logically. 

The  conditions  that  are  most  apt  to  be  mistaken  for  general  paralysis 
are  alcoholism,  syphilitic  insanity,  paralytic  insanity,  certain  cases  of 
epileptic  insanity,  acute  mania  with  ambitious  delusions,  choreic  msanity, 
some  senile  conditions,  some  traumatic  cases,  and  some  imbeciles  with 
stuttering  speech. 

Pathological  Appearances  in  the  Brain  in  General  Paralysis. 
— At  this  point  I  think  it  is  better  to  complete  the  clinical  history  of  the 
disease  by  describing  very  shortly  the  pathological  appearances  met  with 
in  the  brain.  The  encasings  and  supports  of  the  organ  are  all  found  to 
be  affected,  and  the  longer  the  case  has  lasted  the  more  marked  are  the 
changes  met  with.  The  bone  of  the  calvarium  is  denser  and  harder,  in 
many  cases  the  diploe  being  obliterated,  and  in  many  others  there  is  a 
distinct  layering  and  deposit  of  new  bone  on  the  inside  of  the  inner 
table  of  the  skull-cap,  this  being  usually  confined  to  the  frontal  and 
parietal  bones.  The  dura  mater  is  thickened,  adheres  more  or  less  mor- 
bidly, and  fi'equently  leaves  shreds  attached  to  the  bone.  In  many  cases 
I  have  seen  spicula  of  bone  growing  in  it  at  the  junction  of  the  falx, 
which  is  always  much  thickened.  When  the  dura  mater,  often  in  layers, 
is  reflected,  the  most  characteristic  morbid  appearances  of  the  disease  are 
seen.  I  have  endeavored  to  depict  some  of  them  in  Plate  I.  (see  Frontis- 
piece). 

In  a  number  of  cases  we  find,  under  the  dura  mater,  and  attached  to 
it,  lying  between  it  and  the  arachnoid,  a  new  substance  of  a  morbid  and 
peculiar  kind,  commonly  called  a  false  membrane.  It  varies  in  consist- 
ence from  the  fibrous  texture  of  the  dura  mater  itself  to  a  fibreless  jelly, 
in  color  from  a  grayish-white  to  that  of  a  blood-clot,  in  thickness  from  a 
film  to  a  quarter  of  an  inch,  in  extent  from  a  small  patch  or  two  to 
a  covering  of  both  hemispheres  above  and  below.  It  is  usually  thickest 
over  the  vertex.  In  some  cases  it  looks  like  a  clot,  in  others  like  an 
extra  layer  of  dura  mater,  but  it  can  always  be  easily  scraped  away. 
When  it  is  removed  from  the  dura  mater  that  membrane  is  not  congested 
or  inflamed  looking.  It  always  contains  new  bloodvessels,  and  nearly 
always  blood-corpuscles  or  blood-coloring  matter.  On  microscopic 
examination  it  is  found  to  consist  of  a  newly  organized  fibrous  tissue,  in 


GENERAL    PARALYSIS.  273 

a  gelatinous  matrix  with  much  granular  matter,  white  and  red  blood- 
corpuscles,  and  newly  formed  and  forming  capillaries  with  tender  walls. 
This  is  the  so-called  pachymeningitis  Jicemorrhagica  interna  of  the 
Germans,  a  ridiculous  and  misleading  name,  for  it  is  not  the  result 
of  inflammation  at  all.  The  formation  of  the  substance  is,  to  my  mind, 
full  of  interest  and  instructiveness.  It  implies  a  very  great  intensity  of 
morbid  action  in  the  convolutions,  and  probably  also  great  and  sudden 
changes  in  the  blood  pressure  within  the  cranium. 

Under  the  membrane  if  present,  and  under  the  dura  mater  if  not 
present,  we  see  in  all  well-marked  advanced  cases  the  appearance 
presented  in  Plate  I.  on  the  anterior  lobe.  The  arachnoid  is  immensely 
thickened,  and  either  mottled  with  white  spots  or  striated  along  the  sulci 
with  white  fibrous-looking  bands.  Under  it  there  is  what  looks  like 
a  dull  opaque  jelly,  through  which  the  convolutions  dimly  appear,  and 
under  which  great  tortuous  congested  veins  meander ;  some  of  these 
being  perhaps,  if  the  case  has  died  during  or  after  a  congestive  attack, 
obstructed  by  little  white  masses  of  hard  ante-mortem  clot.  But  this  is 
not  really  a  jelly,  for  if  the  arachnoid  is  pricked  it  nearly  all  oozes  out  as 
a  dirty  opaque  fluid,  which  varies  from  two  to  six  ounces  in  quantity. 
This  is  a  really  compensatory  fluid,  filling  up  the  space  left  vacant  by  the 
atrophy  of  the  convolutions  and  brain  generally.  It  does  not  nearly 
represent  the  whole  of  the  brain  atrophy,  for  we  have,  in  addition, 
enlarged  ventricles  and  dilated  perivascular  spaces,  which  often  contain 
six  ounces  more  of  fluid.  After  the  fluid  has  drained  off,  the  pia  mater 
and  the  convolutions  are  better  seen.  Both  are  strikingly  abnormal. 
Thej9m  mater  is  thickened,  vascular,  and  tough  to  an  enormous  extent. 
The  convolutions  are  atrophied,  especially  over  the  vertex  of  the  anterior 
and  middle  lobes  and  in  some  localized  places  elsewhere,  and  generally 
tend  to  be  wedge-shaped,  and  to  lie  loosely  together.  When  the  pia 
mater  is  removed  from  the  convolutions  (do  this  in  every  case  of  mental 
disease  you  examine),  it  is  found  to  adhere  to  and  raise  up  portions  of  the 
outer  layer  of  the  gray  substance  on  the  ridges  of  the  convolutions 
(seldom  in  the  sulci)  which  stick  to  the  pia  mater,  are  removed  with  it, 
and  appear  as  irregular  patches  over  the  membrane  that  has  been 
detached  from  the  brain  (see  lower  part  of  Plate  I.).  The  convolutions 
from  which  those  patches  have  been  removed  look  eroded  like  the  surface 
of  a  cheese  where  a  mouse  has  been  (see  middle  portion  of  Plate).  Now, 
this  adhesion  of  the  pia  mater  to  the  convolutions  is  a  very  morbid 
phenomenon.  It  has  never  been  found  to  any  extent  in  any  patient 
whose  mind  was  sound  and  strong  before  death.  It  is,  in  different  cases, 
confined  to  a  few  convolutions,  or  is  general  over  all  the  brain.  It  is  by 
far  most  frequently  confined  to  the  vertex  and  to  the  anterior  and  middle 
lobes,  and  to  the  gyri  round  the  olfactory  bulbs  at  the  base.  The  two 
hemispheres  usually  adhere  anteriorly,  and  in  the  attempt  to  separate 
them  some  of  the  substance  of  the  convolutions  will  be  torn  away.  In 
some  cases  we  find  this  adhesion  of  the  pia  mater  at  the  base,  over  the 
orbital  convolutions  and  the  middle  lobes.  I  have  never  seen  the  tips  of 
the  posterior  lobes  much  affected.  They  are  usually  healthy  looking. 
Though  the  adhesion  is  only  partial  in  most  cases,  I  have  seen  it  almost 
universal.     It  merely  represents,  in  my  opinion,  the  acme  of  a  pathological 

18 


274  GENERAL    PARALYSIS. 

process  that  is  very  general  in  the  convolutions.  In  examining  the 
different  convolutions  of  the  brain  of  a  general  paralytic  microscopically, 
and  the  different  parts  of  one  convolution,  we  find  that,  though  the 
morbid  appearances  are  in  greater  intensity  in  one  place  than  another, 
they  by  no  means  coincide  in  absolute  intensity  with  the  parts  to  which 
the  pia  matel*  has  adhered.  I  have  found  as  much  disease  microscopically 
in  a  convolution  to  which  it  did  not  adhere  as  in  those  to  which  it  did. 
There  is  rarely  or  ever  much  adherence  of  the  pia  mater  that  dips  down 
into  the  sulci,  and  I  have  never  seen  one  convolution  adhering  to  the 
next.  This  fact  alone  has  always  settled  the  question,  in  my  judgment, 
that  the  disease  is  not  of  inflammatory  origin,  using  that  word  in  its 
ordinary  sense.  The  fact  is,  that  the  pia  mater  which  dips  in  and 
separates  adjoining  convolutions  is  different  in  composition  and  use  from 
that  portion  which  overlays  the  whole  brain.  The  former  contains  no 
lymphatics,  and  is  a  mere  fine  network  of  fibres  to  hold  the  vessels,  while 
the  latter  is  full  of  lymphatic  spaces. 

On  section  the  gray  matter  of  the  convolutions  affected  is  usually 
divided  into  two  distinct  layers,  the  outer  being  gray  and  opaque  looking, 
and  there  is  often  a  line  of  red  congestion  as  the  demarcation  between 
those  two.  Along  this  line  the  brain  tissue  seems  softer  and  more 
pultaceous.  There  is  no  real  sclerosis,  though,  on  the  whole,  the  outer 
layer  of  the  gray  substance  may  be  slightly  harder  in  texture  than 
normal.  In  some  cases,  however,  it  is  distinctly  softer.  The  whole  gray 
matter  is  thinner,  especially  in  the  cases  that  have  lasted  long.  The 
white  substance  is  often  very  congested,  especially  in  irregular  patches  (as 
seen  in  Plate  III.),  its  perivascular  spaces  are  always  enlarged,  and  the 
small  tessels  tough  and  their  coats  thickened. 

On  opening  into  the  ventricles  they  are  nearly  always  found  enlarged. 
but  the  most  striking  peculiarity  is,  that  their  normally  delicate  epithelial 
linings  are  toughened  and  roughened  in  an  extraordinary  degree.  Their 
surfaces  look  in  the  less  marked  cases  like  frosted  glass,  in  the  more 
marked  cases  they  are  granular,  and  even  minutely  nodular,  feeling  rough 
to  the  touch.  They  are  leathery,  too,  when  torn.  This  condition  is 
usually  most  marked  in  the  floor  of  the  fourth  ventricle,  and  the  cover- 
ing of  the  calamus  scriptorius  is  always  a  grayish,  gelatinous-looking, 
but  really  tough  membrane.  The  microscopic  examination  of  a  section 
of  such  a  granulation  at  once  shows  what  has  taken  place  (see  Plate  VII., 
Fig.  3).  The  single  normal  layer  of  delicate  epithelium  has  become 
enormously  hypertrophied,  and  has  thrown  itself  up  into  great  nodular 
masses  of  epithelial  cells,  arranged  in  some  cases  in  layers  of  one 
hundred  cells  deep.  In  the  deeper  layers  the  cells  have  become  flattened 
and  hardened,  so  that  they  have  a  fibrous  appearance,  and  the  brain 
substance  on  which  they  rest  has  undergone  a  process  of  sclerosis.  Those 
granulations  are  in  fact  innumerable  epitheliomata  growing  over  a 
fibrous  membrane.  There  is  no  single  tissue  in  the  brain  Avhose  condi- 
tion is  so  morbid  as  the  epithelial  linings  of  the  ventricles.  This  is 
another  proof,  if  any  were  needed,  that  general  paralysis  is  not  an 
inflammmation  proper,  for  in  inflammation  the  first  thing  the  epithelial 
cells  do  is  to  fall  off  while  it  lasts. 

A  microscopic  examination  of  sections  of  the  convolutions  (see  Plate 


GENERAL    PARALYSIS.  275 

VII.,  Fig.  5)  shows  enormous  proliferation  of  the  neuclei  of  the  neuroglia, 
which  takes  place  most  along  the  small  vessels  and  capillaries.  The 
outermost  layer  of  the  convolutions  is  thinned,  altered  in  appearance  and 
structure,  and  in  the  advanced  cases  converted  into  a  dense  unorganized- 
looking  texture,  instead  of  the  beautiful  and  regular  layer  of  small  cells 
and  fine  granules  of  a  healthy  convolution.  The  larger  cells  further  in, 
and  the  large  multipolar  cells,  are  more  or  less  degenerated  or  atrophied, 
especially  in  patches  and  areas.  The  bloodvessels  are  diseased,  their 
coats  being  thickened  and  full  of  nuclei.  Sometimes  they  are  obliterated 
and  thready.  The  perivascular  canals  are  morbidly  enlarged,  sacculated, 
and  filled  with  all  kinds  of  organic  debris,  blood  coloring-matter, 
granules,  and  minute  apoplexies.  There  can  be  no  doubt  that  those 
canals  and  the  spaces  in  the  pia  mater  act  as  lymphatic  ducts.  Having 
been  obstructed  during  life,  little  eflfete  material  could  have  been  carried 
along  them. 

There  is  no  nervous  tissue  that  is  not  found  diseased  and  degenerated  in 
advanced  cases  of  the  disease,  the  retina,  the  peripheral  nerves,  the 
sympathetic  ganglia,  etc. 

Nature  of  the  Disease. — What,  then,  is  general  paralysis  ?  There 
are  few  diseases  whose  essential  nature  we  as  yet  know.  But  we  know 
that  the  special  trophic  energy  and  inherent  physiological  qualities  of 
different  tissues  become  perverted  in  special  ways,  so  that  most  tissues 
have  their  own  special  types  of  disease.  There  can  be  no  doubt  that  the 
gray  substance  of  the  convolutions  of  the  brain  of  man  is  the  highest  in 
quality  and  function  of  any  organic  product  yet  known  in  nature.  That 
substance  reaches  its  highest  development  in  the  male  sex  between 
adolescence  and  middle  life.  Its  uses  are  called  forth  in  the  highest 
degree  in  the  European  races  who  live  in  towns.  Its  physiological  abuses 
by  alcoholic  and  other  poisoning,  by  over-strain,  by  violent  energizing 
stimulated  by  continuous  strong  mental  and  other  stimuli  up  to  the  point 
of  exhaustion,  are  also  most  common  under  those  circumstances.  Its 
outer  layer  or  rhind  is  most  delicately  constituted,  has  far  more  blood 
(see  Plate  VII.,  Fig.  5)  and  more  minute  cells  than  any  other  portion  of 
the  brain,  and,  on  the  whole,  may  be  regarded  as  the  most  important 
factor  in  mentalization,  being  in  fact  the  mind  tissue.  Immediately 
underlying  it  in  the  convolutions,  in  certain  parts  of  the  brain,  we 
probably  have  the  originating  motor  cells.  This  outer  rhind  of  gray 
matter,  this  last  evolved  and  highest  organic  substance,  is  precisely  that 
affected  in  general  paralysis.  The  proof  goes  to  show  that  this  is  first 
affected  in  the  typical  cases,  and  that  all  the  other  nervous  degenerations 
which  finally  affect  the  whole  nervous  system  are  subsequent  and  sequen- 
tial. Granted  a  progressive  and  incurable  disease  of  this  mind  tissue, 
towards  which  the  whole  of  the  rest  of  the  nervous  system  tends  and  in 
which  it  ends,  which  controls  and  regulates  it  all,  and  which  is  its  crown 
and  highest  development,  it  is  quite  explicable  that  all  the  rest  of  the 
nervous  system  should  degenerate  in  structure  and  function,  and  in  fact 
die  slowly  and  progressively.  It  is  a  quality  of  nerve  tissue  to  degen- 
erate in  the  lines  of  physiological  activity,  when  that  activity  ceases 
either  in  a  higher  centre  or  in  the  part  innervated.  General  paralysis  is 
a  disease  of  this  outer  layer  of  the  cerebral  convolutions — of  the  mind 


276  PARALYTIC    INSANITY. 

tissue  in  fact.  It  is  essentially  a  death  of  that  tissue.  I  look  on  it  as 
being  equivalent  to  a  premature  and  sudden  senile  condition,  senility 
being  the  slow  physiological  process  of  ending,  general  paralysis  the 
quick  pathological  one.  The  causes  of  it  are  causes  that  have  exhausted 
trophic  energy  by  over-stimulation.  Its  first  stage  is  accompanied  by 
undoubted  morbid  vaso-motor  dilatation,  so  that  all  the  tissues  enveloping 
the  brain,  and  holding  its  elements  together,  receive  an  abnormal  supply 
of  blood,  and  thereby  acquire  tissue  hypertrophy — the  bones  of  the  skull- 
cap, the  membranes,  the  reuroglia,  the  epithelium,  and  the  arteries. 
Just  as  the  tissue  degenerations,  especially  the  brain  degenerations  of  old 
age,  cannot  be  arrested,  and  are  necessarily  progressive,  so  is  general 
paralysis.  Those  high  nerve  cells  have  lost  their  once  inherent  power  of 
self-restoration,  and  so  they  degenerate  and  atrophy.  The  diseased 
process  is  peculiar,  because  the  tissue  in  which  it  originates  is  peculiar. 
Its  motor  accompaniments  are  really  not  more  inexplicable  than  the 
ordinary  senile  speech  and  senile  incoordination. 

Local  Distribution, — General  paralysis  prevails  in  some  places  and 
in  some  races,  and  is  unknown  in  others.  As  yet  the  Asiatic  is  not 
subject  to  it,  the  savage  is  free  from  it,  and  the  Irishman  and  Scotch 
Highlander  needs  to  come  to  the  big  towns  or  to  go  to  America  to  have 
the  distinction  of  being  able  to  acquire  it.  The  female  sex  is  very  un- 
susceptible of  it,  but  if  women  drink  bad  liquor  and  live  riotous,  excited 
lives,  as  in  the  cotton  and  manufacturing  districts  of  England,  they  too 
will  become  general  paralytics.  I  have  only  seen  one  female  in  the  rank 
of  a  lady  suffering  from  general  paralysis.  The  things  that  most  excite 
and  at  the  same  time  most  exhaust  the  highest  brain  energy  are  those 
that  tend  most  strongly  to  cause  the  disease,  viz.,  over  and  promiscuous 
sexual  indulgence  combined  with  hard  muscular  labor,  a  stimulating  diet 
of  highly  fed  flesh  meat,  the  brain  being  all  the  while  excited  and  poisoned 
by  alcohol  and  syphilis,  all  these  things  being  begun  early  in  life  and  kept 
up  steadily.  In  this  country  the  Durham  miner,  when  earning  good 
wages,  fulfils  the  most  perfect  conditions  yet  known  for  the  production  of 
general  paralysis.  Every  sixth  lunatic  admitted  to  the  Durham  County 
Asylum  is  a  geneal  paralytic.  Hard  study,  or  severe  mental  shocks,  or 
traumatic  injuries,  or  continuous  anxiety,  will  also  produce  the  disease. 
I  do  not  think  there  is  any  proof  that  it  is  syphilitic  in  origin. 


PARALYTIC    INSANITY. 

Paralytic  Insanity,  or  Organic  Dementia,  is  that  fonn  of  mental  dis- 
turbance which  accompanies  and  results  from  such  gross  brain  lesions  as 
apoplexies,  ramollissements,  tumors,  atrophies,  and  chronic  degenerations 
of  the  brain,  affecting  the  convolutions  and  their  functions  either  primarily 
or  secondarily.  It  has  nothing  whatever  to  dj  with  general  paralysis. 
Its  symptoms  vary  according  to  the  position,  kind,  and  intensity  of  the 
pathological  process.  But  it  is  typically  a  dementia,  an  enfeeblement,  a 
lessening  of  the  mental  power,  superadded  to  some  sort  of  motor  paralysis. 
Along  with  this  enfeeblement  there  may  be,  and  there  usually  is,  a  certain 
amount  of  depression  at  first,  followed  afterwards  by  a  mild  exaltation  and 


PARALYTIC    INSANITY.  277 

emotionalism  of  a  childish  kind,  this  gradually  passing  oiF  and  leaving  the 
patient,  if  he  lives  long  enough,  forgetful,  helpless,  and  torpid.  Paralytic 
insanity,  like  general  paralysis,  has  a  gross  and  demonstrable  pathological 
basis,  but  it  differs  widely  and  essentially  from  it  in  not  being  a  specific 
disease  of  the  brain  convolutions,  in  not  running  a  progressive  course,  in 
not  being  necessarily  incurable,  in  the  irregularity  and  variety  of  the 
mental  symptoms  present,  and  of  the  pathological  lesions.  It  is  best  and 
most  commonly  seen  in  a  case  where  there  has  been  apoplexy  from  rupture 
of  a  bloodvessel  in  one  of  the  great  basal  ganglia,  or  embolism,  or  throm- 
bosis, followed  by  local  starvations  of  brain  tissue,  and  ramollissement ; 
those  destructive  processes  cutting  off  large  tracts  of  the  convolutions  by 
destroying  part  of  the  projection  and  association  systems  of  fibres  by 
which  the  convolutions  are  brought  into  connection  with  the  basal  ganglia, 
the  cerebellum,  and  the  cord  and  the  muscles,  or  with  each  other.  This 
interruption  may  of  itself  sensibly  affect  the  mental  power,  and  those 
pathological  processes  tend  to  advance  up  into  the  convolutions,  so  de- 
stroying the  sources  of  mental  energy  directly.  A  brain  affected  by 
apoplexy  or  embolism,  and  in  that  case  probably  having  its  bloodvessels 
generally  diseased,  is  an  organ  on  the  verge  of  dissolution.  Such  pro- 
cesses are  the  beginning  of  the  end  in  most  cases,  and  the  mental  symp- 
toms are  often  the  most  prominent  and  by  far  the  most  troublesome. 
Yet,  after  all,  they  are  not  the  essential  part  of  the  disease.  This  disease 
is  not  an  insanity  in  the  popular  acceptation.  In  most  cases  the  gradual 
mental  decay  is  never  thought  of  as  a  mental  disease  at  all.  It  is  rather 
looked  on  as  a  necessary  and  natural  accompaniment  of  the  bodily  disease. 
In  most  cases  it  is  not  at  all  beyond  the  ordinary  nursing  capacity  and 
management  available  in  the  patient's  home,  if  he  has  any  money  or 
relatives  at  all.  The  very  poor  in  the  great  towns,  when  affected  by  it, 
are  sent  to  workhouses,  and  not  usually  to  asylums  for  the  insane.  It  is 
only  the  worst  and  most  troublesome  cases  that  it  is  necessary  to  send 
there — the  noisy,  the  restless  at  night,  the  very  dirty,  the  troublesome. 
Motor  restlessness  is  a  special  characteristic  of  the  worst  class  of  cases, 
and  this  often  needs,  for  the  protection  of  the  patient,  special  nursing 
and  special  rooms.  But  there  is  no  essential  difference  between  the 
helpless  hemiplegic  whose  memory  is  gone,  his  energy  impaired,  his 
thinking  capacity  paralyzed,  and  his  affective  power  deadened,  who  sits 
in  his  easy-chair  at  home,  and  the  restless,  shouting,  sleepless  paralytic 
insane  man  in  the  hospital  ward  of  an  asylum. 

The  heredity  of  the  patient  plays  an  important  part  in  the  origination 
of  paralytic  insanity  of  the  more  marked  kind.  While  a  man  with  no 
nervous  heredity  will  have  a  large  spot  of  progressive  softening  in  one  of 
his  corpora  striata,  and  yet  will  be  calm,  reasonable,  and  quite  manage- 
able, though  forgetful,  torpid,  and  emotional,  the  man  with  a  bad  nervous 
heredity  will  become,  under  the  same  conditions,  restless,  depressed,  noisy, 
and  sleepless.  There  is  no  doubt  that  apoplexies  and  all  sorts  of  other 
.  gross  limited  lesions  produce,  in  unstable  brains,  great  convolutional  dis- 
turbance through  reflex  excitation.  If  such  brains  are  unstable  in  their 
motor  centres,  we  have  convulsions,  local  or  general ;  if  there  is  heredi- 
tary mental  instability,  then  we  have  the  ordinary  symptoms  of  mania  or 
melancholia.     I  had  once  as  a  patient  a  young  woman  (G.  N.)  under 


278  PARALYTIC    INSANITY. 

thirty,  who,  having  heart  disease,  became  hemiplegic  on  her  right  side, 
and  aphasic  after  the  birth  of  a  chikl.  Immediately  after  these  came  on 
great  mental  depression,  with  suicidal  tendencies,  for  which  she  had  to 
be  sent  to  an  asylum.  The  hemiplegia  soon  passed  quite  away,  but  the 
aphasia  remained  all  her  life ;  and  when  the  mental  depression  passed  off 
in  a  few  months  she  gradually  became  exalted,  and  remained  so  for  some 
months.  Then  she  again  became  depressed,  and  was  mentally  a  typical 
case  of  alternating  insanity  {J'olie  circulaire)  for  the  seven  years  she  lived 
after  this.  She  at  last  died  of  the  heart  disease,  and  I  found  Broca's  con- 
volution almost  destroyed  by  an  old  embolism,  but  the  rest  of  the  brain 
with  only  the  traces  of  repeated  excitations  and  congestions.  In  this 
case,  which  I  mention  as  being  a  very  rare  and  most  unusual  kind  of 
paralytic  insanity,  the  embolism  and  its  consequences  no  doubt  excited 
into  pathological  activity  a  previously  existing  hereditary  weakness  of 
the  mental  portions  of  the  convolutions  which  had  before  that  been  stable 
in  their  working.  In  the  more  typical  cases  of  paralytic  insanity  the 
same  thing  occurs  in  old  and  partially  worn-out  brains. 

There  is  a  close  analogy  in  symptoms,  pathology,  and  course,  between 
paralytic  and  senile  insanity.  In  fact,  the  majority  of  paralytic  cases  are 
also  senile.  In  a  brain  with  general  senile  degeneration  and  diseased 
arteries,  a  local  lesion  occurs,  and  we  have  it  exciting  and  lighting  up  a 
general  convolutional  flame.  I  have  had  many  cases  where  there  was  a 
family  tendency  to  mental  disease,  but  it  had  never  shown  itself  in  any 
actual  symptoms  till  the  very  end  of  life,  when  an  attack  of  paralysis 
occurred,  and  this  was  followed  by  melancholic  or  maniacal  symptoms 
and  subsequent  dementia.  I  have  had  several  such  patients  whose 
children  had  become  insane  at  an  early  age  long  before  them,  but  they 
remained  well  till  they  became  hemiplegic.  One  such  case  was  G.  0., 
set.  67,  who  remained  quite  well  mentally,  and  did  his  work  till  he  had 
a  slight  attack  of  left  hemiplegia.  Then  he  became  melancholic,  sleepless, 
and  suicidal,  and  had  to  be  sent  to  the  asylum,  where  his  daughter,  G.  P., 
had  been  a  patient  for  thirteen  years,  suffering  from  essential  paralysis  g^ 
infancy  on  the  right  side,  epilepsy,  and  dementia. 

The  motor  symptoms  in  paralytic  insanity  must  be  regarded  as  integral 
parts  of  the  disease.  The  speech  is  the  most  characteristic  of  these  in 
the  ordinary  hemiplegic  cases.  It  is  a  thick  articulation,  not  a  tremulous 
speech.  Every  word  from  the  beginning  of  a  sentence  to  the  end  is  im- 
perfectly pronounced.  There  is  no  tendency  to  fail  more  at  the  end  of  a 
sentence  than  at  the  beginning.  The  labial  and  facial  muscles  do  not 
quiver  before  or  during  the  articulatory  process,  as  in  general  paralysis, 
though  the  tongue  usually  trembles  when  put  out.  It  is  a  simple  paretic, 
not  a  convulsive,  speech.  Long,  diflScult  words  and  sentences  are 
attempted,  and  got  through  with  in  a  way,  but  are  not  found  impossible 
of  attempt,  or  end  in  a  more  inarticulate  prolonged  vowel  sound,  as  often 
in  general  paralysis.  In  the  latter  disease  it  is  essentially  a  convolu- 
tional lesion  speech ;  in  the  former  it  is  a  basal  motor  ganglia  lesion 
speech.  In  the  former  it  is  the  originating  motor  speech  coordinations 
in  the  convolutions  that  are  affected,  in  the  latter  the  secondary  coordi- 
nations lower  down.  In  very  many  of  the  paralytic  cases  we  have 
apoplexies  and  similar  lesions  of  the  convolutions  themselves,  and  in  such 


PARALYTIC    INSANITY.  279 

the  speech  symptoms  are  always  more  like  those  of  general  paralysis. 
In  such  patients,  too,  we  are  apt  to  have  epileptiform,  epileptic,  and  con- 
gestive attacks.  In  many  instances,  even  when  the  original  lesion  has 
been  in  the  corpoi'a  striata  or  in  the  motor  fibres  of  conduction  near  it, 
desti'uction  of  tissue  will  go  on  up  to  the  convolutions ;  in  fact,  if  the 
patient  lives  long  enough  it  is  sure  to  do  so,  and  the  speech  will  become 
more  like  that  of  the  second  stage  of  general  paralysis. 

I  need  hardly  say  that  if  the  lesion  affects  the  posterior  portion  of  the 
third  frontal  convolution  of  the  left  side,  or  the  Island  of  Reil  on  that 
side,  or  the  fibres  of  communication  inwards  from  those  parts,  or  certain 
portions  of  the  extra-ventricular  nucleus  of  the  corpus  striatwn  of  that 
side — in  such  cases  we  will  have  the  aphasic  speech  symptoms.  It  is  a 
disputed  question  whether  complete  aphasia  can  coexist  with  perfect 
integrity  of  the  intellectual  faculties.  If  the  lesion  be  strictly  limited  to 
the  speech  centre,  which  it  very  rarely  is,  the  loss  of  mental  power  may 
be  slight,  but  whether  we  can  have  mental  completeness  according  to  the 
previous  standard  of  perfect  health  of  the  individual  is  another  matter. 
I  do  not  believe  we  can  have  such  completeness  if  we  could  apply  proper 
tests.     I  have  never  seen  a  case  where  it  existed. 

Here  is  a  kind  of  case,  very  common  indeed  where  extreme  bodily 
helplessness  coexisted  with  such  mental  symptoms  as  made  the  patient's 
presence  almost  intolerable  in  a  private  house,  and  even  to  the  neighbors 
who  lived  near. 

G.  Q.,  ?et.  64.  Had  an  attack  of  apoplexy  with  left  hemiplegia  four 
months  before  it  was  necessary  to  send  her  to  the  asylum.  Her  mother 
died  of  apoplexy  at  the  age  of  eighty -four.  There  was  no  other  neurotic 
heredity  discoverable.  During  the  first  month  after  the  apoplexy  she 
was  stupid  and  half  comatose.  Then  she  began  to  have  hallucinations 
of  sight,  and  to  be  fanciful,  irritable,  and  very  unreasonable,  to  sleep 
badly,  and  to  have  a  morbid  craving  for  food  with  no  sense  of  satiety. 
The  mental  symptoms  got  gradually  worse,  while  the  hemiplegia  remained 
complete.  She  became  subject  to  periodic  fits  of  depression,  lasting 
whole  days  and  nights,  during  which  she  would  cry  and  scream  loudly 
without  intermission  in  a  peculiar  baby-like  voice  that  penetrated  through 
the  house  and  into  the  street,  and  was  most  annoying  to  the  neighbors, 
especially  at  night.  There  was  no  reasoning  with  or  soothing  her.  It 
was  evident  that  she  had  a  sense  of  extreme  organic  discomfort,  and  that 
she  probably  had  pain.  Her  delusions  all  took  their  origin  from  her 
sensations.  She  affirmed  that  her  left  leg  and  arm  did  not  belong  to  her, 
and  would  order  that  they  should  be  taken  away.  She  affirmed  her  food 
was  poisoned,  and  she  said  the  people  near  her  were  going  to  kill  her. 
She  could  not  attend  to  the  calls  of  nature,  and  when  moved  to  be 
dressed  and  washed  screamed  at  the  pitch  of  her  voice.  She  had  no 
memory  at  all  for  recent  events,  but  lived  in  the  past.  She  was  very 
emotional,  crying  nearly  every  time  she  was  spoken  to,  but  her  appear- 
ances of  emotion,  like  the  rest  of  her  mental  life,  were  merely  automatic. 
She  showed  no  real  affection  for  her  famil3^  She  constantly  threatened 
suicide.  She  mistook  the  identity  of  those  about  her,  calling  strangers 
by  the  names  of  old  friends.  With  the  hand  she  could  move  she  would 
try  to  tear  and  destroy  and  break  things.     After  about  three  months  of 


280  PARALYTIC    INSANITY. 

this  state  she  had  to  be  sent  to  the  asylum,  chiefly  on  account  of  the 
noise  she  made. 

She  "was  fed  and  nursed  and  cared  for,  placed  on  a  water-bed,  and 
kept  warm,  and  placed  in  a  room  where  her  noise  did  not  disturb  others. 
Sedatives  and  soporifics,  such  as  the  bromides  and  chloral,  were  tried  in 
moderate  doses.  They  usually  did  not  act  in  producing  quiet  or  sleep 
till  twelve  hours  after  they  Avere  given.  This  is  a  common  thing  in 
maniacal  conditions.  An  old  night  attendant  I  once  had  pointed  it  out 
first  to  me.  He  divided  his  noisy  people  into  two  classes — those  in  whom 
the  night  draughts  produced  sleep  the  night  they  were  given,  and  those 
in  whom  they  produced  sleep  only  on  the  following  night.  Though  sleep 
was  thus  produced  in  G.  Q.'s  case,  it  was  not  restful  or  in  any  way  bene- 
ficial, while  her  appetite  was  lessened  and  her  strength  impaired.  After 
frequent  repetitions  of  the  bromide  of  potassium  and  chloral  she  got 
quite  drowsy,  stupid,  and  would  take  no  food  at  all.  It  seemed  as  if  the 
only  things  to  be  done  with  benefit  were  nursing  and  feeding.  The 
advanced  and  advancing  brain  disease  being  destructive  and  irritative  in 
its  character,  evidently  involving  the  convolutions  to  a  serious  extent, 
seemed  capable  of  no  alleviation.  She  steadily  got  weaker,  and  died  in 
about  four  months  from  the  beginning  of  the  attack.  No  post-mortem 
examination  was  permitted.  The  case,  looked  at  from  the  point  of  view 
of  mental  symptoms,  was  one  of  melancholia  of  the  excited  variety ;  but 
the  whole  of  the  mental  symptoms  were  so  secondary,  in  a  clinical  point 
of  view,  to  the  attack  of  apoplexy  and  hemiplegia,  that  it  is  evident  the 
appropriate  name  for  such  a  case  is  that  of  paralytic  insanity.  The 
irregular  periodicity  in  the  symptoms,  and  the  days  of  quiet  she  had, 
seemed  to  me — and  this  is  markedly  the  case  in  many  senile  cases  too — 
to  be  merely  the  stupor  and  inaction  of  a  spent  organ,  that  could  no 
longer  evolve  morbid  energy  through  sheer  exhaustion  till  an  accumu- 
lation again  took  place. 

The  following  is  a  good  example  of  insanity  from  an  advancing 
paralysis,  not  hemiplegic  at  first,  caused  by  progressive  brain  destruction : 

G.  R.,  set.  57.  Habits  intemperate.  No  admitted  heredity  to  the 
neuroses.  Four  years  before  admission  to  the  asylum  he  had  some  sort 
of  attack  that  was  described  as  "bilious,"  becoming  almost  blind  after  it. 
He  then  became  subject  to  severe  headaches.  About  fifteen  months 
before  admission  he  had  a  paralytic  shock,  affecting  both  sides  equally, 
and  since  then  his  mental  power  has  gradually  become  impaired.  At 
times  he  was  noisy  and  unruly  in  a  stupid,  purposeless  fashion,  thinking 
that  some  one  was  coming  to  hurt  him.  When  he  could  not  find  his 
razor  one  day  he  set  fire  to  his  beard.  He  would  attempt  to  leave  the 
house  with  nothing  but  his  night-shirt  on.  He  slept  badly,  and  was 
restless,  and  often  noisy  at  night.  He  used  to  repeat  his  former  acts  in 
an  automatic  absurd  way,  e.g.,  one  day  was  found  fishing  in  his  grate 
with  a  bit  of  string  tied  to  a  stick.     His  memory  especially  failed. 

When,  on  account  of  the  excitement,  noise,  and  difiiculty  of  manage- 
ment at  home,  he  was  sent  to  the  asylum,  he  was  not  apparently  exalted 
or  depressed  or  excited,  but  he  was  much  enfeebled  in  mind,  his  speech 
and  behavior  being  childish,  and  his  memory  almost  gone.  He  could 
not  tell  the  day  of  the  week,  or  his  age,  or  the  number  of  his  children. 


PARALYTIC    INSANITY.  281 

He  expressed  no  delusions.  His  power  of  attention  was  lessened.  He 
evinced  no  great  surprise  or  curiosity  at  coming  to  the  asylum.  His  face 
was  expressionless  and  flabby,  bis  gait  dragging  and  weak,  and  bis  grasp 
feeble.  His  articulation  was  cbaracteristic  of  sucli  cases,  being  tbick 
and  slurred,  but  not  tremulous.  It  Avas  simply  a  muscular  inability  to 
perform  tbe  fine  coordinations  of  speecb.  The  tongue  was  furred,  flabby, 
and  tremulous  on  its  surface.  The  bowels  were  constipated.  Heart 
enlarged,  and  sounds  impure.  The  sensibility  and  reflex  action  were 
normal.    The  urine  was  slightly  albuminous.    Temperature  98°,  pulse  84. 

After  coming  to  the  asylum,  there  was  a  steady  downward  course  in 
mind  and  body.  He  was  restless,  and  very  liable  to  fall  over  any  little 
obstacle  and  hurt  himself.  He  slept  badly.  He  was  perfectly  contented 
in  mind;  but  if  you  spoke  in  a  sympathetic  tone,  he  would  burst  out 
crying  without  being  able  to  assign  any  cause.  At  first  he  was  able  to 
keep  himself  clean,  but  soon  his  urine  and  then  his  feces  passed  without 
his  paying  any  attention.  At  night  he  was  often  noisy  and  very  restless, 
and  he  needed  to  have  his  bed-clothes  put  on  and  be  attended  to  by  the 
night  attendant  constantly.  Was  placed  in  our  infirmary  ward,  and 
needed  much  attention  by  day  and  night.  In  four  months  he  was  con- 
fined to  bed,  and  almost  entirely  paralyzed,  but  still  noisy.  Then  he  got 
in  a  condition  of  semi-stupor,  and  in  eight  months  after  admission  had 
an  attack  of  apoplexy  with  left  hemiplegia  and  coma,  and  died  in  twenty- 
four  hours  thereafter.  The  whole  disease  lasted  four  years,  during  the 
last  two  of  which  he  was  partially  paralyzed  and  affected  in  mind,  and 
for  the  last  eight  months  he  needed  asylum  treatment.  A  post-mortem 
examination  was  not  allowed. 

The  following  is  an  example  of  the  kind  of  recovery  that  sometimes 
take  place  in  paralytic  insanity: 

G.  S.,  aet.  62,  a  steady,  temperate  man.  His  sister  was  a  patient  in 
the  asylum  once.  Two  years  before  admission  he  had  had  two  shocks  of 
paralysis  on  the  left  side.  Since  then  he  has  got  more  and  more 
"nervous,"  and  at  times  noisy  and  violent.  For  six  weeks  before  ad- 
mission he  had  been  distinctly  insane.  He  was  poor,  and  poorly  attended 
to  at  home.  On  admission  he  was  childish,  facile,  suspicious,  and  talka- 
tive. He  thinks  the  house  is  coming  down  on  him,  that  a  surgical  opera- 
tion was  performed  on  him  yesterday,  and  that  people  are  watching  him 
to  do  him  harm,  and  many  other  changing  fancies.  He  could  walk,  but 
dragged  slightly  the  left  leg.  He  had  a  paralytic,  thick  articulation.  His 
heart  was  diseased.  He  steadily  improved  und<n-  a  good  diet,  regulated 
exercise  and  work,  and  general  supervision,  till  in  three  months  he  left 
the  asylum  quite  sane  and  able  to.  earn  his  own  livelihood,  though  not 
strong-minded.  He  worked  as  a  gardener  for  tAvo  years,  and  then  was 
sent  back  to  the  asylum  with  much  the  same  symptoms  as  at  first.  The 
mental  symptoms  and  the  hemiplegia  again  disappeared  almost  entirely, 
and  in  seven  months  he  was  able  to  leave  the  asylum.  Though  not  able 
to  work  much,  he  has  stayed  quietly  at  home  with  his  son  ever  since — 
for  three  years  now. 

Among  the  causes  of  paralysis  and  paralytic  insanity,  other  than 
apoplexies  and  ramollissements,  the  most  interesting  in  relation  to  the 
mental  symptoms  they  produce  are  brain  tumors.     They  are  various  in 


282  PARALYTIC    INSANITY. 

kind,  position,  and  mode  of  growth,  and  those  conditions  all  aiFect  the 
symptoms  bodily  and  mental.  Some  tumors  grow  slowly,  and  their 
effects  can  be  traced  to  intracranial  pressure  alone.  In  many  such  no 
symptoms  have  been  present  during  life  at  all,  or  no  symptoms  that 
could  lead  to  a  correct  diagnosis.  Other  tumors  cause  violent  irritation, 
direct  and  reflex,  in  the  brain  tissues  near  and  distant.  Others  cause 
destructive  lesions,  and  especially  ramollissements  in  the  brain  tissue 
near  them.  Others  set  up  slow  progressive  changes  both  in  near  and 
distant  parts  of  the  brain  and  the  organs  of  special  sense.  Intense 
cephalalgia  is  undoubtedly  the  most  common  sensory  symptom.  There 
are  no  headaches  like  those  caused  by  tumors  of  the  brain.  They  some- 
times stupefy  and  "drive  the  patient  mad."  Next  to  those,  optic  neuritis 
and  blindness  are  the  most  common  symptoms.  The  motor  signs  are 
paresis  and  paralysis  local  and  general,  convulsions  local  and  general, 
and  congestive  attacks ;  in  these  as  in  other  respects,  mentally  and  bodily, 
imitating  general  paralysis.  The  mental  symptoms  most  common  in 
cases  with  brain  tumor  are,  first,  irritability  and  loss  of  self-control,  and 
"change  of  disposition,"  then  depression,  with  or  without  excitement, 
then  confusion,  loss  of  memory,  muttering  to  self,  loss  of  interest  in  all 
things,  perhaps  delirious  attacks,  then  drowsy  half-consciousness,  ending 
in  coma  and  death.  Such  cases  may  die  in  a  month,  or  may  run  on  to 
twenty  years  from  the  beginning  of  the  symptoms.  Different  authors 
have  had  extraordinarily  different  experiences  as  to  the  frequency  of 
brain  tumors  from  two  per  thousand  up  to  twenty-eight  per  thousand 
deaths  among  the  insane,  which  latter  has  been  my  own  experience.  It 
is  doubtful  whether  brain  tumors  are  more  frequently  found  in  autopsies 
in  lunatic  asylums  than  in  general  hospitals. 

The  following  is  an  interesting  and  very  typical  case^  of  insanity  from 
tumor,  which  illustrates  nearly  all  the  common  mental  and  bodily  symp- 
toms of  that  disease: 

G.  T.,  aet.  38.  First  attack  of  insanity ;  no  hereditary  predisposition 
so  far  as  can  be  ascertained;  was  intemperate  in  his  habits,  which  is 
given  as  the  predisposing  cause  of  his  insanity,  the  exciting  cause  being 
evidently  organic  disease  of  brain ;  has  shown  symptoms  of  insanity  for 
four  years.  His  first  mental  symptoms  seem  to  have  consisted  in  a 
change  of  temper,  great  irritability,  and  an  altered  affection  for  his  wife 
and  fiimily.  His  first  bodily  symptoms  were  intense  cephalalgia  and  a 
gradually  increasing  blindness,  this  last  preceding  by  some  time  the 
mental  alienation.  He  has  been  getting  much  worse  mentally  of  late — 
being  excessively  irritable,  violent  to  his  wife  and  daughters,  very  abusive 
and  foul  in  his  language,  and  then  would  accuse  his  wife  of  all  the 
violence.  He  still  drank  hard  when  he  could  get  whiskey,  and  all  his 
mental  symptoms  were  very  much  worse  after  drinking.  He  professed 
to  be  sorry  for  his  violence  and  bad  temper  afterwards.  The  blindness 
became  complete,  and  he  also  became  slightly  deaf  shortly  before  his 
admission.  During  the  twelve  months  before  admission  he  had  several 
"epileptic"  attacks.  He  wished  to  go  to  the  asylum,  and  walked  there 
with  a  friend. 

^  For  this,  along  with  other  cases  of  mine,  and  more  full  observations  on  the  mental 
accompaniments  of  hrain  tumors,  see  Journal  of  Mental  Science,  July,  1872. 


PARALYTIC    INSANITY.  283 

On  admission  he  showed  slight  signs  of  excitement  and  confusion  of 
mind,  but  his  memory  was  good.  He  was  quite  coherent,  and,  on  the 
whole,  sharp  and  intelligent.  Could  answer  questions  correctly,  and  had 
no  delusions.  He  was  a  heavy-looking  man,  with  the  blind  expression 
of  face — his  features  combining  the  expression  of  an  advanced  general 
paralytic  and  that  of  a  man  who  is  drunk.  His  gait  was  affected  like  that 
of  a  tipsy  man.  His  speech  was  thick  and  rather  indistinct.  He  was  quite 
blind,  and  was  deaf  in  his  right  ear.  He  said  he  had  at  times  cramp  in 
his  legs.  Reflex  action  in  legs  normal.  Right  pupil  more  dilated  than 
left,  and  both  nearly  insensible  to  light.  Lungs  and  heart  normal. 
Appetite  good,  tongue  very  white,  bowels  costive,  temperature  97.8°, 
pulse  72,  good. 

He  remained  in  the  state  described  for  the  first  fortnight,  except  that 
on  the  very  slightest  provocation  he  became  wild  with  passion — com- 
pletely losing  control  over  himself,  and  capable  of  doing  any  violence  to 
those  about  him.  In  a  fortnight  he  had  a  severe  epileptiform  fit,  and  was 
quite  unconscious  after  it,  but  he  was  as  usual  next  morning.  He  had 
such  attacks  frequently  ever  afterwards.  For  the  first  six  months  there 
was  little  change  in  him.  After  that  he  got  more  obtuse  in  mind,  weaker 
and  more  paralyzed  in  his  legs,  his  articulation  thicker  and  more  indis- 
tinct, his  pharynx  more  insensible  and  paralyzed,  so  that  he  would  have 
choked  himself  on  any  solid  food.  In  nine  months  his  legs  were  quite 
paralyzed,  and  his  conjunctivae  became  at  first  injected  and  then  ulcerated, 
with  ulcers  of  the  corneae.  During  the  whole  time  he  suffered  from  the 
disease,  an  excessive  irritability  with  violent  paroxysms  of  passion,  often 
coming  on  without  any  cause,  were  his  chief  mental  characteristics. 
Towards  the  end  of  his  life,  a  clouding  of  his  faculties  took  place,  he 
slept  much,  and  immediately  before  death  he  was  semi-comatose.  Reflex 
action  in  his  legs  continued  very  acute  to  the  last.  He  died  in  ten 
months  after  admission,  and  about  five  years  from  the  beginning  of  the 
disease. 

At  the  post-mortem  examination  the  following  appearances  were  found : 

Head. — Calvarium  hard  and  heavy,  but  not  very  thick.  When  it 
was  removed  a  very  curious  appearance  was  presented.  Over  the  surface 
of  the  dura  mater  there  were  a  great  many  little  cauliflower-like  ex- 
crescences scattered  irregularly,  being  most  numerous  along  the  middle 
line,  and  the  largest  in  the  locality  of  the  Pacchionian  bodies.  The  base 
of  each  was  surrounded  by  a  bulging  of  the  dura  mater,  and  where 
attached  to  this  each  was  quite  small,  forming  a  short  pedicle.  They 
varied  in  size  from  a  pea  to  a  bean ;  they  looked  like  little  projections 
of  brain  that  had  been  made  to  squirt  out  through  small  holes  in  the 
dura  mater  by  slow  steady  pressure  from  within — little  herniae  of  the 
brain.  Each  had  a  very  thin  fibrous  covering  continuous  with  the  dura 
mater.  In  color  they  resembled  a  mixture  of  gray  and  white  substance  ; 
in  consistence  they  seemed  to  be  nearly  that  of  ordinary  brain  convolu- 
tion. Each  had  a  clearly  cut  bed  absorbed  out  of  the  bony  skull-cap, 
only  leaving  a  transparent  plate  of  bone.  There  was  a  large  one  over 
the  right  orbital  plate,  the  size  of  a  bean,  causing  complete  absorption  of 
the  bone,  so  that  it  projected  into  the  fat  behind  the  eye.  On  attempting 
to  raise  the  dura  mater,  it  was  found  that  this  could  not  be  done  without 


284  PARALYTIC    INSANITY. 

tearing  the  connection  of  these  hernise  Avith  the  convolutions.  At  the 
narrowest  part  of  the  neck  of  each,  as  it  passed  through  the  dura  mater, 
it  consisted  of  both  white  and  gray  matter,  so  that  when  torn  oft'  there 
was  a  small  white  spot  like  a  pin's  head  in  the  convolution  from  which  it 
sprung.  On  section  it  was  seen  that  this  w4iite  substance  passed  through 
the  gray  matter  of  the  convolution  like  a  stalk,  and  was  continuous  with 
the  ordinary  white  brain  substance  ;  and  outside  of  the  dura  mater  it  ex- 
tended into  each  hernia,  swelling  out  and  forming  its  centre,  with  a  thin 
covering  of  gray  substance.  By  gentle  pressure  from  without  a  consider- 
able part  of  some  of  the  excrescences -could  be  pressed  back  ;  the  hernia 
could,  as  it  were,  be  partially  reduced,  but  this  broke  up  to  a  greater 
extent  what  was  evidently  slightly  softened  brain  substance  already. 

When  the  brain  was  lifted  up  a  large  tumor  was  found  attached  to  the 
right  side  of  the  cerebellum  and  along  part  of  the  right  crus  cerebri, 
pressing  on,  and  causing  partial  absorption  of  that  part  of  the  pons 
Varolii  and  cerebellum.  It  was  firmly  attached  to  the  fibrous  portioa 
of  the  temporal  bone,  causing  absorption  of  the  bone,  and  entering  into 
and  disorganizing  the  internal  ear  of  that  side.  It  pressed  on  the  lower 
portion  of  the  middle  lobe  of  the  cerebrum,  causing  complete  ramollisse- 
ment  there,  so  that  the  fluid  in  the  ventricle  ran  out  at  that  part.  The 
tumor  was  hard  and  fibrous  in  some  parts,  soft  and  cystic  in  others,  gray 
in  color,  and  somewhat  irregular  in  outline,  being  altogether  about  as 
large  as  a  hen's  egg. 

The  ventricles  were  much  enlarged,  and  contained  much  fluid.  On 
section  there  were  spots  of  ramoUissement  over  right  orbit,  at  base  of 
middle  lobe  of  right  side,  and  in  corpus  striatum  of  right  side,  the  white 
substance  being  generally  doughy.  Optic  nerves  and  tracts  gray  and 
fibrous. 

Microscopic  Examination. — On  a  microscopic  examination  of  the 
brain  substance  in  the  fresh  state,  the  covering  of  each  excrescence  was 
found  to  consist  of  fibrous  tissue,  being  thinned  dura  mater.  The  inside 
consisted  of  masses  of  granules,  and  in  some  places  there  was  a  striated 
appearance,  being  the  remains  of  white  nerve-fibres.  The  arteries  were 
coated  in  most  places  with  granular  matter.  On  examination  of  the 
pedicles  of  the  excrescences,  the  granular  cells  were  not  so  numerous,  and 
the  striation  of  the  white  fibres  was  perfect.  At  the  surface  of  the  brain 
the  appearance  was  that  of  healthy  white  brain  substance.  Altogether 
the  morbid  appearances  were  more  marked  at  the  outside  of  each  hernia. 
On  examining  sections  of  convolutions,  hardened  in  chromic  acid,  and 
cut  and  prepared  by  Stirling's  method,  it  was  found  that  the  bloodvessels 
were  very  much  enlarged  and  tortuous,  and  surrounded  by  granular 
matter  and  a  great  number  of  round  vacant  spaces  in  each  section. 
Probably  these  had  contained  some  morbid  product,  such  as  masses  of 
granular  matter,  which  had  fallen  out,  or  been  dissolved  by  the  turpentine 
and  spirit  in  the  process  of  preparation. 

Statistics  of  Paralytic  Insanity. — In  the  nine  years,  1874-1882, 
we  have  had,  out  of  3145  admissions  to  the  Royal  Asylum,  Edinburgh, 
91  cases  diagnosed  as  paralytic  insanity.  That  is  nearly  3  per  cent.  Of 
those  91  cases,  17,  or  almost  19  per  cent.,  recovered  mentally.  This  was 
one  of  the  results  of  statistical  inquiry  into  special  forms  of  insanity  that 


PARALYTIC    INSANITY.  285 

surprised  me.  Had  I  been  asked  before,  I  should  have  said  that  it  was 
quite  a  rare  thing  for  a  case  of  paralytic  insanity  to  recover.  But  this 
shows  that  when  a  gross  lesion  of  the  brain  first  occurs,  it  often  sets  up 
a  convolutional  storm  of  mania  or  melancholia,  which  is  temporary  and 
curable.  The  immediate  mental  effect  is  of  the  nature  of  a  reflex  irrita- 
tion, or  temporary  vascular  congestion,  which  subsides  like  any  other 
maniacal  or  melancholic  attack.  Ten  cases  were  discharged  more  or  less 
improved,  in  addition  to  the  seventeen  recoveries.  Forty-six  of  the 
patients  have  died  up  to  this  time,  in  thirty-six  of  whom  post-mortem 
examinations  were  performed. 

Pathology  of  Paralytic  Insanity. — Looking  at  the  pathology  of 
paralytic  insanity,  as  disclosed  in  the  records  of  the  pathological  appear- 
ances found  in  those  thirty-six  cases,  one  sees  that  ordinary  brain  dis- 
integrations ("Avhite  and  yellow  softenings")  from  embolism  and  throm- 
bosis stand  as  the  most  frequent  lesion.  These  "softenings"  existed  in 
eighty-three  per  cent,  of  the  cases.  Their  most  frequent  original  seat 
was  in  the  basal  ganglia,  but  in  most  of  the  cases  the  disintegration  had 
extended  into  the  white  substance  round  those  ganglia  more  or  less.  In 
only  about  twenty  per  cent,  of  the  whole  number  was  there  manifest  dis- 
integration of  the  convolutions.  In  four  of  the  patients  the  lesion  was 
confined  to  the  convolutions,  was,  in  fact,  a  true  disease  of  the  convolu- 
tions alone.  These  had  been  epileptiform.  In  five  cases  only  were  there 
adhesions  of  the  pia  mater  to  the  convolutions,  and  in  two  of  these  the 
whole  pathological  appearances  so  resembled  those  of  general  paralysis 
that  I  think  they  had  been  instances  of  that  disease,  complicated  by 
ordinary  softenings  in  the  basal  ganglia.  There  was  very  marked 
atrophy,  with  or  without  softenings  of  the  convolutions  in  twelve  cases, 
or  one-third  of  the  whole  number.  Through  atrophy,  or  adhesion  of  the 
pia  mater,  or  disintegration,  or  the  pressure  of  tumors,  the  convolutions 
were  manifestly  diseased  in  twenty-seven  of  the  thirty-six  cases,  or  seventy- 
five  per  cent.  This  gives  so  far  a  definite  pathology  to  paralytic  insanity, 
by  showing  that  it  is  not  merely  through  lesions  of  the  basal  ganglia  and 
their  reflex  convolutional  disturbances  that  it  occurs,  but  through  appre- 
ciable disease  of  the  convolutions  themselves,  in  three-fourths  of  the 
patients  that  die.  I  have  no  doubt  that  microscopic  examination  would 
have  shown  the  convolutions  affected  in  a  still  larger  number  of  cases. 

The  frequency  of  tumors  was  surprising.  They  were  found  in  seven 
of  the  thirty-six  cases.  In  most  of  them  there  was  manifest  convolutional 
secondary  lesion,  through  pressure  or  irritation,  in  addition  to  the  tumors. 
In  one  case  a  spiculum  of  bone  projected  into  the  pons  from  the  base  of 
the  calvarium,  setting  up  thickening  and  inflammatory  action.  The 
atrophy  in  two  cases  was  of  that  kind  which  affected  chiefly  the  white  sub- 
stance in  the  centre  of  one  hemisphere,  leaving  the  gray  substance  of  the 
convolutions  like  a  crust  round  a  hollow  space  (like  the  case  figured  in 
Plate  v.).  There  were  recent  hemorrhages  in  only  three  of  the  cases ; 
and  there  were  purulent  deposits  in  one. 

It  may  be  concluded,  therefore,  that  gross  brain  lesions,  wherever 
situated,  tend  to  cause  mental  disease  in  two  ways — first,  by  reflex  or 
other  irritation,  or  excitation  of  morbid  convolutional  action ;  and,  sec- 
ondly, by  actual  destruction,  primary  or  secondary,  of  convolutional 
structure. 


LECTUREXI. 

EPILEPTIC  INSANITY— TRAUMATIC  INSANITY. 

The  motor  neurosis  called  epilepsy  may  exist  in  every  form,  and 
according  to  every  definition,  without  being  associated  witli  such  mental 
disturbance  that  it  could  be  called  insanity.  Whether  we  hold  epilepsy 
to  comprise  every  motor  spasm,  even  the  slightest,  or  restrict  it  to  the 
periodic  recurrence  of  general  convulsions  accompanied  by  unconscious- 
ness, it  may  exist  without  insanity.  But,  on  the  other  hand,  in  a  very 
considerable  proportion  of  cases,  epilepsy  has  as  its  accompaniment 
mental  disturbances,  amounting  often  to  insanity.  And  a  very  important 
form  of  insanity  it  is.  Long  before  Dr.  Skae  classified  mental  diseases 
clinically,  epileptic  insanity  was  recognized  and  named.  From  the 
earliest  times  its  mental  accompaniments  have  increased  the  mystery  and 
terror  of  epilepsy.  When,  added  to  the  contortions  and  unconsciousness 
of  that  disease  during  a  fit,  there  were  afterwards  developed  strange 
hallucinations,  terrible  acts  of  impulsive  violence,  and  striking  religious 
delusions,  we  cannot  wonder  that  a  supernatural  cause  was  almost 
universally  believed  in  of  old.  No  demon  could  by  any  possibility  pro- 
duce more  fearful  efiects  by  entering  into  a  man  than  I  have  often  seen 
result  from  epilepsy. 

The  first  great  fact  to  be  kept  in  mind,  in  regard  to  epilepsy  in  its 
mental  relations,  is  that  the  frequent  recurrence  of  epileptic  fits  for  many 
years  tends  in  some  degree  to  impair  the  mental  faculties,  to  dim  the 
reasoning  power,  to  twist  or  take  the  fine  edge  off"  the  feelings,  emotions, 
and  sensibilities,  to  afi'ect  the  memory,  to  lessen  the  self-control,  and  to 
change  the  "  character,"  even  where  there  is  no  actual  insanity.  If  a  man 
only  takes  a  few  fits  in  his  lifetime,  and  they  are  far  between,  there  may 
be  no  mental  accompaniment  whatever,  except  the  unconsciousness  at 
the  time  and  the  transient  confusion  after  each  fit.  And,  beyond  a 
doubt,  the  occurrence  of  such  rare  fits  is  compatible  with  great  mental 
power.  Julius  Caesar  and  Mahomet  are  said  to  have  had  such  occasional 
attacks  of  epilepsy. 

When  I  speak  of  epilepsy  causing  insanity  and  mental  symptoms,  you 
must  clearly  understand  that  the  whole  series  of  symptoms,  bodily  and 
mental,  may  in  some  cases  be  the  combined  result  of  a  general  disturb- 
ance of  function  or  of  disease  in  the  brain,  neither  the  convulsions  being 
the  primary  disease,  nor  the  mania,  but  both  being  equally  effects  of  the 
same  cause.  It  is  usual  for  the  epileptic  insanity  not  to  follow  at  once 
the  first  appearance  of  the  fits.  Most  commonly  years  elapse  before  it- 
comes  on.  No  doubt  the  more  severe  and  the  more  frequent  the  fits  the 
greater  is  the  risk  of  insanity,  but  certain  epileptics  suffer  merely  a 
gradual  mental  clouding  and  diminution  after  years  of  epilepsy,  while 
others  have  furious  mania  very  soon  after  the  first  fits  have  appeared. 


EPILEPTIC    INSANITY,  287 

It  would  seem  as  if  certain  cases  of  epilepsy  from  the  beginning  con- 
sisted essentially  in  their  nature  quite  as  much  of  a  mental  as  of  a  motor 
instability  and  explosiveness.  I  do  not  agree  with  Hughlings  Jackson 
that,  in  cases  of  jyetit  mal  and  slight  convulsions,  the  explosion,  not 
finding  vent  in  a  motor  fonn,  is  more  apt  to  extend  up  into  mental 
centres.  There  are  some  few  such  cases,  but  in  my  experience  only  a 
few.  The  theory  is  fascinating,  but  there  is  danger  in  making  too  close 
an  analogy  between  a  mental  disturbance  and  an  ordinary  motor  convul- 
sion, and  in  regarding  them  as  virtually  the  same  thing,  the  one  being  an 
"explosion"  in  a  "mental  centre"  and  the  other  in  a  motor  centre.  I 
admit  that  such  a  view  is  most  instructive  as  a  hypothesis  and  help  in 
making  definite  one's  ideas,  and  in  some  rare  cases  of  epileptic  insanity 
seems  to  fit  the  facts  exactly,  and  explain  the  apparently  substitutionary 
character  of  the  convulsion  and  the  psychosis.  But  in  nineteen  cases 
out  of  twenty  of  epileptic  insanity,  the  mental  symptoms  are  not  of  the 
sudden  explosive  character  at  all,  as  we  shall  see,  and  they  are  by  no 
means  attended  with  unconsciousness  or  false  consciousness,  loss  of 
memory,  and  want  of  power  of  attention.  The  theory  of  explosion 
assumes  that  you  have  a  morbid  energy  developed  in  such  brains  that 
will  act  in  some  form,  just  like  a  charge  of  gunpowder,  which,  if  you 
obstruct  the  muzzle,  will  blow  out  the  breach  of  your  gun. 

Epileptic  insanity,  and  by  this  I  mean  all  the  morbid  mental  effects 
associated  with  the  disease,  occurs  in  relation  to  the  fits  in  six  chief  ways : 
(1)  After  them.  This  is  on  the  whole  the  most  common,  and  the  mental 
symptoms  then  seen  are  essentially  periodic  and  paroxysmal,  like  the 
motor  convulsions.  They  follow  usually  within  twenty-four  hours  of  the 
fit  or  fits.  If  there  have  been  a  series  of  fits,  they  are  much  more  apt  to 
occur  than  after  one  only.  (2)  Before  the  fits.  They  usually  show 
themselves  a  day  or  two,  rarely  three  or  four,  before  a  fit  is  coming  on. 
And  in  such  cases,  when  the  fit  occurs,  the  mental  irritability,  suspicions, 
impulsiveness,  or  confusion,  usually  disappears  at  once,  its  place  being 
taken  by  a  stupidity,  or  in  some  cases  by  normal  mentalization.  This  is 
undoubtedly  a  strange  fact,  but  is  abundantly  seen.  Our  attendants  in 
asylums  can  tell  in  this  way  when  a  fit  is  coming  on  in  many  of  the  epi- 
leptics under  their  care.  The  fit,  like  a  thunderstorm,  seems  to  clear  the 
air.  (3)  Mental  disturbance  may  occur,  instead  of  the  fits,  taking  their 
place,  apparently  coming  on  at  the  period  when  the  fits  might  have  been 
expected.  This  is  rare,  but  very  instructive.  It  is  the  epilepsie  larvee, 
or  masked  epilepsy,  of  the  French,  and  seems  to  favor  Hughlings 
Jackson's  explosion  theory  of  epilepsy  more  than  any  other  clinical  fact 
observed  in  connection  with  this  disease.  (4)  A  slow,  steadily  progressing 
loss  of  memory  and  change  of  afiection,  a  blunting  of  the  finer  feelings, 
and  a  permanent  mental  obscuration  or  twisting,  those  being  often  the 
very  first  symptoms  present,  growing  more  intense  the  longer  the  patient 
lives  and  takes  the  fits.  This  is,  in  fact,  a  dementia  either  from  brain 
injury  by  the  fits  or  from  the  natural  advance  through  prolongation  of  the 
morbid  brain  state  that  caused  the  epilepsy.  Most  epileptics  tend  to 
become  demented  if  they  live  long  enough.  The  arrest  of  mental  devel- 
opment, and  the  degeneration  towards  idiotic  conditions  seen  in  nearly 
all  cases  where  epilepsy  occurs  early  in  life,  come  under  this  heading. 


288  EPILEPTIC    INSANITY. 

(5)  Some  forms  of  chronic  insanity  take  the  place  of  the  fits,  which  cease 
altogether.  I  have  seen  only  four  or  five  cases  where  this  took  place,  and 
they  all  occurred  at  the  termination  of  the  reproductive  period  of  life. 

(6)  Epilepsy  may  begin  in  the  course  of  chronic  insanity  of  many  years' 
duration,  evidently  through  advance  of  disease  from  the  mental  into  the 
motor  centres  of  the  brain.  I  do  not  mean  a  mere  sporadic  convulsion 
or  series  of  convulsions,  in  the  course  of  a  case  of  recent  or  chronic 
insanity,  such  as  I  have  described  in  that  form  of  melancholia  which  I 
have  called  convulsive,  or  like  those  cases  of  alcoholic  or  syphilitic 
insanity  in  which  convulsions  play  a  part.  I  refer  to  those  cases  of 
chronic  insanity,  usually  dements,  who  become  epileptic,  beginning  to 
take  regular  periodic  fits  after  being  many  years  insane,  and  then  going 
on  taking  them  regularly.  I  have  seen  about  a  dozen  such  cases,  and 
now  have  five  such  under  my  care. 

It  will  be  observed  that  all  these  relationships  point  to  a  close  connec- 
tion between  the  locus  in  quo  of  epilepsy  in  the  brain  and  the  seat  of 
mental  disturbance.  The  fact  that  they  are  related  to  each  other  in  such 
various  ways  is  the  strongest  proof  of  the  nearness  of  their  pathological 
seat.  The  experimental  demonstration  of  a  motor  function  in  the  convo- 
lutions seems  to  be  strongly  confirmed  by  all  the  clinical  facts  of  epileptic 
insanity.  Hereditarily  ordinary  insanity  and  epilepsy  are  closely  allied. 
The  son  or  daughter  of  an  epileptic  is  just  as  likely  to  be  idiotic,  weak- 
minded,  drunken,  or  insane,  as  to  be  epileptic  ;  and  certainly  the  children 
of  families  with  a  strong  insane  heredity  are  very  commonly  epileptic. 

The  actual  mental  symptoms  caused  by,  or  associated  with,  epilepsy 
vary  considerably,  as  we  shall  see  from  the  cases  that  will  be  related ;  but 
there  is  a  certain  type  of  psychosis  so  common  as  to  be  almost  character- 
istic. Two  words  express  its  most  marked  characteristics,  irritability  and 
impulsiveness.  I  suppose  one  may  look  on  these  as  representing  a  morbid 
state  of  nutrition  and  energizing  of  the  brain  convolutions,  whereby  there 
is  a  morbid  energy  evolved  and  a  want  of  inhibition  to  control  it.  The 
epileptic  psychosis  may  exist  in  every  degree  from  the  merest  excess  of 
irritable  temper  up  to  the  most  dangerous  homicidal  impulses  and  acts. 
I  have  seen  epileptic  insanity  take  the  form  of  a  more  acute  maniacal 
condition  than  almost  any  other  insanity.  Before  the  days  of  the 
bromide  of  potassium,  and  its  regular  use  in  the  cases  of  most  epileptics 
in  asylums,  no  patients  were  so  troublesome  or  dangerous.  There  is  no 
form  of  insanity  that,  outside  asylums,  is  more  frequently  the  cause  of 
murders  except,  perhaps,  the  alcoholic.  Hence  its  medico-legal  importance 
to  medical  men  and  jurists.  It  depends  much  on  the  strength  and  intel- 
ligence of  the  medical  evidence  whether  an  epileptic  murderer  is  hanged 
or  sent  to  Broadmoor.  If  a  man  has  been  subject  to  regular  epileptic 
fits,  and  commits  a  murder  in  an  impulsive  or  motiveless  way,  then  I 
think  the  presumption  would  be  very  strong  that  he  was  not  fully 
responsible  for  his  actions.  No  prejudice  or  want  of  knowledge  on  the 
part  of  judges  or  juries  should  prevent  a  medical  man  from  giving  clear 
evidence  on  this  point.  A  murder  by  an  epileptic  should  usually  be 
looked  on  as  being  as  much  a  symptom  of  his  disease  as  larceny  by  a 
general  paralytic. 

A  certain  religious  emotionalism  of  a  strong  and  usually  perverted 


EPILEPTIC    INSANITY.  289 

kind  is  often  present  in  epileptics.  We  have  now  a  lad  (C.  W.)  in  whose 
anti-bromide,  and  therefore  natural,  epileptic  clinical  history  it  was  a  sure 
prelude  to  a  fit,  or  series  of  fits,  that  he  took  his  Bible,  read  it  continu- 
ously, and  when  spoken  to  would  answer  fiercely — "  Don't  trouble  me, 
I'm  a  good  man,  I'm  a  servant  of  God."  The  day  after,  he  would  be 
walking  up  and  down,  striking  any  patient  or  anyone  else  who  ventured 

to  speak  to  him,  replying  maniacally — "  You're  a  d d  liar  !     Don't 

insult  me  I"  if  one  remarked  to  him  it  was  a  fine  day.  That  night  he 
would  have  one  or  two  fits,  and  would  be  stupid  and  much  inclined  to 
masturbation.  Next  day  he  would  keep  his  bed,  and  after  a  day  or  two 
would  get  up  and  go  about  as  usual.  The  bromide  treatment,  in  doses 
of  twenty  grains  three  times  a  day,  has  utterly  destroyed  the  typical 
psychosis  as  Avell  as  diminished  the  number  of  fits,  for  he  is  now  a  mild, 
industrious,  slightly  weak-minded  young  man,  Avho  does  what  he  is  told, 
and  only  takes  a  fit  every  six  months,  instead  of  a  series  of  them  every 
month. 

As  illustrating  epileptic  irritability  not  reaching  this  maniacal  stage, 
look  at  those  two  women,  G.  X.  and  G.  Y.  The  one,  G.  X.,  rages  at 
her  attendant,  calls  her  a  murderess,  affirms  that  she  has  given  her  no 
food  to-day  (she  has  just  had  her  dinner,  eating  half  of  it  and  throwing 
the  remainder  at  the  attendant),  and  that  she  has  tried  to  poison  her 
often.  Nothing  you  can  say  to  her  but  will  rouse  anger.  No  remark, 
however  mild,  but  will  excite  a  storm  of  scolding.  No  soothing  influence 
will  mollify  her  in  the  least  degree.  She  tries  to  imitate  your  voice. 
She  is  sarcastic,  abusive,  and  threatening  by  turns,  as  I  demonstrate  the 
failure  of  the  psychological  experiment  of  a  soft  answer  being  able  to 
turn  away  wrath.  By  the  way,  that  psychological  aphorism  is  more 
applicable  in  dealing  Avith  the  insane  than  almost  any  other  class  of 
human  beings.  It  stands  me  in  good  stead  many  times  every  day;  and 
if  I  could  only  practise  it  always  myself,  and  get  my  attendants  to  prac- 
tise it,  we  should  save  many  rows,  and  avoid  on  many  occasions  the  use 
of  physical  force.  But  I  am  bound  to  say  it  altogether  fails  sometimes, 
and  notably  in  this  patient,  and  in  other  epileptics.  But  just  try  the 
opposite  tack,  and  contradict  her  and  tell  her  sharply  that  she  is  an 
unreasonable  woman,  who  is  talking  nonsense  and  acting  like  a  fool. 
How  this  aggravates  all  her  symptoms  I  She  shouts,  and  at  once  threatens 
personal  violence.  "  Never  contradict  or  attempt  to  reason  with  an  epi- 
leptic when  excited,"  is  an  axiom  in  asylums.  I  Avish  we  could  get  our 
attendants  always  to  practise  it.  Now,  this  Avoman  had  a  fit  two  days 
ago,  and  by  to-morroAV  her  irritability  will  have  passed  off,  and  she  will 
be  a  quiet,  civil,  and  agreeable  woman. 

The  next  patient,  G.  Y.,  is  in  much  the  sdme  general  condition  of 
morbid  irritability.  She  sings  a  psalm  tune  in  a  noli  me  tangere  tone  of 
voice.  When  I  ask  her  mildly  what  tune  that  is,  she  denounces  me  as 
a  hypocrite  and  a  scoundrel,  says  I  am  of  the  seed  of  the  devil,  and  that 
she  is  one  of  God's  people,  and  of  the  seed  of  Israel.  This  delusion 
recurs  Avhenever  she  has  fits.  She  describes  visions  she  has,  in  which  she 
sees  Jesus  Christ  and  the  prophets.  At  times  she  has  the  hallucination 
that  she  is  surrounded  by  flames,  and  sees  eyes  like  fiery  balls  glaring  at 
her.     She  is  almost  never  amiable,  is  subject  to  morbid  suspicions  and 

19 


290  EPILEPTIC    INSANITY. 

aversions  to  certain  people.  Her  social  instincts  have  been  almost  up- 
rooted by  her  disease. 

In  both  those  cases  the  bromide  has  been  tried,  and  failed  to  do  good. 
This  has  partly  resulted  from  the  fact  that  the  trial  was  imperfect,  for 
they  both  believed  it  was  poison  given  to  do  them  harm,  resisting  and 
refusing  it,  and  partly  because  the  epilepsy  they  are  both  subject  to  is 
nocturnal.  This  is  never  so  subdued  by  the  bromides  as  the  fits  taken 
by  day,  and  the  epileptic  psychosis  associated  with  nocturnal  epilepsy  is 
also  unamenable  to  the  good  effects  of  the  drug.  Epileptic  insanity  is 
not  nearly  so  common  among  women  as  men,  whatever  may  be  the  case 
with  uncomplicated  epilepsy ;  and  when  it  occurs  it  is  less  benefited  by 
the  bromides  in  most  cases.^ 

Next,  let  us  take  a  case  of  typical  epilepsy  and  typical  epileptic  in- 
sanity in  a  man,  a  patient  that  illustrates  a  great  many  clinical  facts  of 
an  instructive  kind: 

H.  A.  was  said  to  have  been  thrown  from  his  palanquin  in  India  at 
the  age  of  seventeen,  and  to  have  alighted  on  the  left  side  of  his  head. 
He  did  not  suffer  much  at  the  time,  and  had  no  epileptic  fits  till  seven 
years  afterwards  when  home  on  furlough.  Yet  on  this  slight  j^ost-Jioc 
the  epilepsy  was  put  down  to  the  fall  in  India.  Relatives  will  always 
assign  some  cause  for  such  a  disease.  There  have  been  neuroses  and 
mental  disease,  but  no  epilepsy,  in  the  family.  The  fits  began  in  March 
one  year,  and  were  numerous  and  severe.  They  usually  came  on  about 
every  month,  but  sometimes  every  day  or  two.  In  September  following 
he  had  a  severe  maniacal  attack,  for  which  he  was  sent  to  the  asylum. 
It  was  accompanied  by  unconsciousness,  and  a  constant  rotating  motion 
from  left  to  right,  the  eyes  staring  in  a  fixed,  glassy  way.  His  condition 
was,  in  fact,  more  a  stupor  with  motor  restlessness.  This  is  not  an 
uncommon  kind  of  epileptic  psychosis.  This  lasted  for  ten  days,  and  he 
then  got  well.  He  had  a  pain  in  the  left  side  of  his  head,  especially 
before  the  fits,  and  his  left  ann  in  the  fits,  especially  in  the  clonic  spasm, 
twitched  more  than  the  right.  It  was  thought  that  those  things  pointed 
to  a  depression  of  bone,  or  some  such  local  irritation,  at  the  part  where 
he  fell.  The  late  Mr.  Syme  trephined  the  bone  at  the  spot,  taking  out  a 
circle  about  the  size  of  a  halfpenny.  A  "very  questionable  alteration" 
in  the  bone  was  thought  to  be  detected.  "No  alteration  Avas  detected  on 
microscopic  examination."  In  a  week  he  had  a  maniacal  attack,  without 
having  any  fits,  during  which  he  was  most  violent — shouting,  struggling, 
recognizing  no  one.  To  prevent  him  injuring  the  wound  he  was  kept  in 
bed  by  a  number  of  sheets  and  skeins  of  worsted.  This  lasted  for  a 
fortnight,  when  he  got  well  again.  For  three  months  he  kept  well,  and 
was  discharged  from  the  asylum  "relieved,"  having  no  fits  for  four 
months  after  the  operation.  He  then  became  depressed  in  mind  and 
emotional,  weeping  much.  Tliis,  as  a  temporary  phase  of  epileptic 
psychosis,  is  not  uncommon.  He  then  had  several  fits,  which  were 
followed  within  two  days  by  an  acute  attack  of  mania,  with  frenzied 
violence.  He  was  put  in  restraint  in  the  sheets  again,  as  his  scalp  was 
tender,  and  he  threw  himself  against  the  walls  of  the  room.     As  he  got 

'  For  the  exact  statistics,  see  Journal  of  Mental  Science  for  October,  1868. 


EPILEPTIC    INSANITY.  291 

out  of  the  unconscious  maniacal  state  he  Avas  irritable,  unreasonable,  and 
complained  of  everything.  Nothing  or  nobody  could  please  him.  This 
was  the  very  opposite  of  his  natural  disposition,  which  was  most  consid- 
erate and  gentlemanly.  In  four  months  after  this,  he  had  a  recurrence 
of  the  fits  and  a  maniacal  attack.  He  then  took  the  fits  occasionally 
during  the  next  six  months  without  there  being  any  mania.  But  he  was 
liable  to  sudden  short  attacks  of  epileptic  psychosis,  during  which  he 
would  suddenly  strike  out  at  those  near  him,  or  his  expression  of  face 
would  change  and  become  furious,  while  he  would  stare  at  any  one  beside 
him,  and  shout  fiercely — "  What  the  devil  do  you  mean,  sir?"  This  state 
would  occasionally  come  on  of  itself  without  any  exciting  cause,  but  would 
sometimes  be  set  up  by  contradiction,  or  when  he  saw  anything  done  that 
he  disapproved  of.  I  remember  being  one  of  a  party  of  four  playing 
whist,  he  being  one.  We  were  playing  quietly,  not  a  word  being  said, 
when  he  suddenlj^  let  go  his  cards,  stared  at  his  partner  with  his  eyes 
"rolling  out  of  his  head,"  and,  with  a  damnatory  exclamation,  sprang  at 
his  throat  over  the  table.  He  was  seized,  held  gently  on  the  sofa  for  a 
few  minutes,  came  to  himself,  asked  what  had  been  up,  and  we  went  on 
with  the  game.  He  remembered  nothing  about  what  had  occurred.  This 
is  what  Hughlings  Jackson  would  call  an  attack  of  "mental  epilepsy." 
He  then  began  to  take  the  fits,  about  one  every  week,  nearly  always 
during  the  day.  He  was  subject  to  various  sensory  neuroses,  as  most 
epleptics  are,  such  as  sensations  of  pins  and  needles  in  his  limbs,  a  feel- 
ing as  if  there  were  twitchings  in  his  head,  especially  after  going  to  bed 
and  before  going  to  sleep,  numbness  in  his  left  thumb,  and  tic  in  his  right 
eye  and  temple. 

All  sorts  of  treatment  were  tried  for  the  disease — morphia  by  mouth 
and  subcutaneously,  sulphates  of  zinc  and  copper,  severe  purgation, 
counter-irritation,  colchicum,  and  alkalies,  but  while  he  seemed  to  be  a 
little  better  for  each  drug,  he  soon  was  the  same  as  ever.  Occasionally 
he  would  pass  two  months  without  a  fit,  except  perhaps  a  few  attacks  of 
petit  mal.  In  1865  he  was  put  on  the  bromide  of  potassium  in  ten- 
grain  doses  three  times  a  day.  In  a  month  he  said  he  felt  much  better 
in  health,  had  no  nervousness,  and  little  of  the  twitching  feeling.  His 
general  health  became  better.  For  five  months  he  took  this,  and  had  five 
tits  in  that  time,  only  one  of  them  being  severe,  and  he  had  no  maniacal 
excitement.  The  dose  was  then  doubled,  that  is,  he  took  twenty  grains 
thrice  a  day.  For  one  hundred  days  after  that  he  had  only  two  attacks 
oi petit  mal,  then  he  had  a  slight  fit.  He  kept  so  well  in  mind  that, 
after  a  year  of  the  bromide  treatment,  he  left  the  asylum  on  probation, 
being  charged  to  go  on  with  the  medicine.  He  stayed  at  home  for  six 
months,  and  did  Avell.  Then  he  began  to  take  the  fits  rather  more  fre- 
quently, taking  about  two  or  three  in  the  month  of  a  slight  character. 
He  then  came  back  to  the  asylum  voluntarily,  not  being  maniacal.  The 
fits  almost  always  come  on  just  after  waking  or  during  sleep  about  5  A.  M., 
thus  changing  their  character  from  day  to  night  fits.  Bromide  acne  used 
to  trouble  him,  and  he  would  on  that  account  stop  the  medicine,  but  he 
always  had  a  fit  within  three  days  after  this. 

For  two  years  he  continued  to  take  fits  about  every  month  or  six  weeks, 
but  was  never  maniacal.     Taking  the  fits  in  the  morning,  he  entered  into 


292  EPILEPTIC    INSANITY. 

the  amusements  of  the  asylum,  playing  billiards,  cricket,  dancing,  etc. 
Of  one  thing  he  never  could  be  made  to  realize  the  importance,  and  that 
was  the  risk  he  ran  in  dangerous  places  on  account  of  a  fit  suddenly  coming 
on.  This  was  like  all  epileptics.  He  would  constantly  stand  near  the 
fire,  or  walk  near  steep  places.  When  at  a  picnic  at  the  Falls  of  the 
Clyde  once,  he  went  quite  near  one  of  them  to  look  over.  When  warned 
of  the  risk,  he  coolly  remarked  that  life  would  not  be  worth  having  if  he 
were  always  thinking  of  the  risks  from  a  fit.  It  seemed  to  me  the 
bromide  treatment  not  only  lessened  the  irritability  of  temper  and  the 
number  of  maniacal  attacks,  but  that  it  prevented  the  mental  degenera- 
tion in  feelings  and  manners  which  long-continued  epilepsy  is  apt  to  cause. 

He  had  a  severe  fit  and  a  maniacal  attack  after  it  in  1870,  for  the  first 
time  for  four  years,  during  which  he  was  most  violent,  sang  at  the  pitch 
of  his  voice,  and  knew  nobody.  During  this  paroxysm  he  cut  his  hand 
severely  with  the  glass  in  breaking  a  Avindow.  He  had  no  severe  maniacal 
attack  after  that  for  two  years,  though  taking  the  fits.  In  September, 
1872,  he  took  a  fit  by  day  when  standing  with  his  back  to  an  open  fire ; 
he  fell  backwards,  and  burned  himself  most  severely  in  the  gluteal  region, 
causing  a  sore  of  nine  inches  in  diameter.  For  nine  months  after  this, 
while  the  sore  was  discharging  much  pus,  he  had  no  fits,  though  taking 
no  bromide.  This  I  have  seen  very  frequently  in  epileptics.  Then  his 
fits  began  again,  but  were  very  infrequent.  His  lungs  then  began  to  be 
affected.  In  about  a  year  the  wound  healed,  and  then  for  the  first  time 
since  the  burn  he  had  a  mild  maniacal  attack.  The  lung  disease  gradually 
progressed,  and  he  died  in  two  years  and  a  half  after  the  burn.  He  had 
not  a  trace  of  mania  and  very  few  fits,  for  the  last  nine  months  of  his 
life,  during  which  his  lungs  were  very  far  gone. 

On  post-mortem  examination,  the  dura  mater  was  found  adherent  to 
the  lower  surface  of  the  circular  hole  made  in  trephining  the  skull-cap, 
and  was  adherent  below  to  the  arachnoid  and  pia  mater.  There  were 
no  spiculse  or  thickenings  of  the  bone  towards  the  brain  anywhere.  On 
the  left  side  of  the  spot  operated  on  the  pia  mater  was  adherent  to  a  brain 
convolution.  The  arachnoid  was  slightly  milky,  and  there  was  consider- 
able vascularity  in  the  brain  substance,  with  some  little  perivascular 
atrophy.  Otherwise  the  brain  was  normal,  and  the  medulla  was  not 
congested,  though  the  vessels  were  enlarged. 

The  condition  of  the  brain  did  not  confirm  the  idea  of  an  injury  from 
the  original  fall,  and  threw  no  light  on  the  cause  of  the  epilepsy. 

In  this  one  case  you  see  there  existed  at  different  times,  and  under 
different  circumstances,  epileptic  irritability ;  epileptic  mania  with  and 
without  consciousness,  the  latter  at  times  being  wildly  delirious  and  in 
the  highest  degree  dangerous  to  the  patient  and  those  near  him  ;  epileptic 
impulsiveness  of  action  and  violence ;  epileptic  stupor ;  epileptic  de- 
pression ;  epileptic  false  consciousness  ;  epileptic  automatism  ;  the  charac- 
teristic epileptic  want  of  realization  of  the  dangers  to  which  the  liability 
to  take  the  fits  any  moment  exposes  the  patients ;  epileptic  sensory  neu- 
roses ;  the  temporary  improvements  that  counter-irritation  and  new  modes 
of  treatment  are  apt  to  produce  in  epilepsy ;  the  decided  relief  of  many 
of  the  symptoms  by  the  use  of  the  bromide  of  potassium,  which  yet  does 
not  cure,  and  acts  best  at  first ;  the  cessation  of  the  fits  and  of  the  ten- 


EPILEPTIC    INSANITY.  298 

dency  to  maniacal  outbursts  when  serious  bodily  diseases  come  on  ;  lastly, 
the  present  unsatisfactory  pathology  of  the  disease  was  also  illustrated. 

Epileptic  insanity  should  be  studied  along  with  the  symptomatological 
class  of  impulsive  insanity,  with  which  it  is  very  nearly  allied  in  symptoms 
and  heredity.  I  have  already  alluded  to  the  case  of  E.  L.  (p.  238),  so 
many  of  whose  children  died  of  convulsions,  and  whose  brother  is  an 
epileptic  patient  in  the  asylum.  It  is  also  closely  allied  to  somnam- 
bulism. Epileptic  insanity  proper  is  accompanied  by,  and  complicated 
with,  some  of  the  most  extraordinary  and  irregular  mental  phenomena. 
I  have  a  man,  H.  B.,  who  at  times  has  hallucinations  of  smell,  fancying 
the  air  is  polluted  round  him  by  putrid  meat ;  another,  H.  C,  who 
affirms  that  we  cause  itching  and  formication  of  his  skin,  he  scratching 
himself  violently  after  tits  sometimes.  I  have  known  a  ""  fit  of  itching  " 
come  on  him  instead  of  an  epileptic  fit.  We  have  several  epileptics  who 
receive  messages  from  the  Deity  after  fits.  I  have  a  woman,  H.  D.,  who, 
before  and  after  a  fit,  and  while  she  is  taking  it,  for  she  does  not  lose  her 
consciousness,  imagines  she  has  two  heads,  and  that  one  is  under  her  own 
control  and  the  other  under  the  control  of  an  enemy.  In  her  case  the 
fits  are  unilateral  at  first.  I  have  a  man,  H.  E.,  in  Avhom  an  aphasic 
attack  comes  on  and  lasts  for  periods  from  one  hour  to  three  days,  instead 
of  epilepsy,  he  being  meanwhile  rational,  cheerful,  and  industrious,  and 
writing  on  paper  anything  he  has  to  say  or  answers  to  questions. 

Suicidal  impulses  are  not  common  in  epileptic  insanity.  When 
present,  they  usually  result  from  hallucinations  of  hearing  voices  telling 
the  patient  to  commit  the  act.  I  had  lately  a  well-marked  case  of  this 
sort,  H.  F.,  a  man  aged  thirty -nine  when  he  was  sent  to  the  asylum,  who 
had  been  subject  to  epilepsy  for  several  years,  and  had  often  been  maniacal. 
During  one  of  his  attacks  he  had  bitten  ofi"  his  father's  nose,  under  the  de- 
lusion that  he  Avas  calling  him  bad  names.  When  well  he  was  attached 
to  him.  He  had  exposed  himself  to  some  of  the  strongest  causes  of  brain 
disease,  for  he  had  drank  hard  (epileptics  very  often  do),  had  contracted 
syphilis,  and  exceeded  with  women,  and,  when  a  soldier  in  India,  had 
been  exposed  to  the  sun  and  had  sunstroke.  When  admitted  he  was  very 
violent  and  homicidal.  He  heard  voices,  as  if  it  were  his  fellow-patients 
calling  him  foul  and  ofiensive  names,  such  as  "thief,"  "scoundrel," 
"beggar,"  etc.  He  would  often  assault  savagely  men  who  were  not 
speaking  to  him  at  all.  He  took  the  fits,  which  were  of  the  ordinary 
character,  about  every  fortnight.  The  hallucinations  and  homicidal 
tendency  were  usually  worst  before  the  fits,  but  he  was  always  irritable, 
sullen,  unsocial,  and  had  a  very  strong  and  uncontrollable  craving  for 
drink  and  tobacco.  He  was  put  on  the  bromide  of  potassium  in  twenty- 
five-grain  doses  three  times  a  day.  At  first  it  seemed  to  have  no  effect, 
but  after  about  six  months  he  became  mentally  changed  for  the  better. 
He  got  chatty,  amiable,  and  industrious.  He  had  occasional  outbursts 
of  sullenness  and  irritability,  but  seldom  was  violent.  He  had  the  hallu- 
cinations of  hearing  very  often,  but  he  said  he  disregarded  them,  and 
latterly  said  he  had  got -himself  to  believe  by  reasoning  that  they  were 
"voices"  only,  and  not  the  words  of  actual  men.  If  he  took  liquor,  he 
was  always  worse  in  temper  and  conduct,  and  was  apt  to  have  morbid 
suspicions   and  hallucinations  badly   afterwards.      At   times   he  would 


294  EPILEPTIC    INSANITY. 

request  to  be  put  into  his  bedroom  alone,  to  be  quiet  and  out  of  the  way 
of  the  temptation  of  assaulting  his  fellow-patients.  After  being  in  the 
asylum  two  years  he  had  a  short  paroxysm  of  mania,  and  broke  open  his 
room  shutter  and  got  out,  but  was  recaptured  before  he  went  away.  He 
afterwards  said  that  the  voices  had  been  telling  him  to  go  and  throw  him- 
self over  the  Dean  Bridge,  which  is  the  chief  temptation  to  dramatic 
suicide  in  Edinburgh.  He  improved  much  after  that,  and  took  no 
epileptic  fits ;  on  one  occasion,  for  eighteen  months,  never  needed  seclu- 
sion, got  the  parole  of  the  grounds,  and  went  into  Edinburgh  so  see  his 
relations  occasionally.  No  suicidal  attempt  was  ever  thought  of  by  me 
in  his  case.  The  fits  had  become  slightly  more  frequent,  however,  in 
spite  of  the  bromide.  When  out  one  day  he  went  into  town  for  a  walk 
with  two  fellow-patients,  was  perfectly  cheerful,  and  even  jovial ;  met  his 
brother,  and  chatted  pleasantly  with  him,  saying  he  would  be  out  again 
"next  Saturday."  On  his  way  home  he  said  to  his  companions  that  he 
was  going  to  a  urinal,  went  down  a  by-street,  and  then  as  straight  as  he 
could  go  he  made  for  the  Dean  Bridge  and  threw  himself  over,  killing 
himself  instantly.  This  was  two  years  after  the  time  he  said  the  voices 
told  him  to  do  so,  and  for  twelve  months  before  he  might  have  gone  and 
done  so  any  day,  so  far  as  any  restraint  in  the  asylum  was  concerned. 
On  post-mortem  examination,  I  found  the  pia  mater  over  the  whole 
vertex  of  the  brain  strongly  adherent  to  the  convolutions,  and  the  ven- 
tricles granular,  just  like  a  typical  case  of  general  paralysis.  In  fact,  I 
never  saw  any  case  of  that  disease  with  those  pathological  appearances 
much  more  marked. 

The  homicidal  acts  of  epileptics  are  done  under  the  most  various  cir- 
cumstances, are  widely  different  in  character  in  different  cases,  and  even 
in  the  same  case  at  different  times,  sometimes  are  done  reasoningly  from 
conscious  insane  motives,  sometimes  apparently,  but  not  really  reason- 
ingly, because  without  consciousness  or  memory.  An  epileptic  may 
scheme  to  do  an  act  of  insane  violence  and  try  to  conceal  it  carefully 
afterwards.  They  are  most  apt  to  take  unfounded  dislikes,  especially  to 
their  relations  and  those  near  them.  The  conscious  anger  will  pass  into 
the  epileptic  unconscious  mania  in  a  moment  sometimes.  One  of  the 
most  extraordinary  things  I  ever  knew  was  this :  A  young  epileptic, 
H.  G.,  who  was  veiy  friendly  with  me  when  he  was  well,  used  to  dislike 
me  very  much  when  excited  after  fits.  On  one  occasion  the  attendant 
found  him  and  another  patient  contriving  to  make  up  a  weapon,  with 
which  to  assault  me  or  the  chief  attendant,  out  of  a  stocking  which  the 
epileptic  had  taken  off,  put  a  stone  in  the  toe  of  it,  tied  a  string  about  this, ' 
and  had  then  slipped  it  up  his  sleeve  till  he  should  have  a  chance  of  using 
it.  When  he  got  out  of  the  epileptic  mental  condition,  he  was  astonished 
when  told  about  this,  and  said  he  had  no  recollection  of  it  whatever, 
which  I  believed  to  be  true.  The  combination  with  another  patient,  and 
the  purposive  combined  preparation  of  a  lethal  weapon,  all  in  a  state  of 
epileptic  unconsciousness,  I  could  not  have  believed  possible  had  I  not 
seen  them  in  that  patient.  Supposing  this  man  had  not  been  in  the 
asylum  and  had  combined  with  another  in  preparing  a  weapon,  waiting 
for  an  opportunity,  and  had  committed  murder ;  and  then  supposing  a 
doctor  had  gone  into  the  witness-box  and  given  evidence  that  the  murderer 


EPILEPTIC    INSANITY.  295 

was  quite  irresponsible  on  account  of  his  being  in  a  state  of  epileptic 
insanity,  and  quite  unconscious  of  his  acts  at  the  time,  with  what  lofty 
scorn  would  the  judge  have  put  aside  such  evidence  as  being  inherently 
incredible !  With  what  dogmatic  assertion  the  newspapers  would  point 
to  such  an  example  of  a  medical  man  trying  to  defeat  justice  and  screen 
a  criminal !  What  lively  ridicule  the  journals  would  have  poured  upon 
evidence  so  "opposed  to  common  sense  and  to  law  I"  And  all  this 
because  a  fact  of  nature  and  of  disease  had  been  brought  out  before  those 
who  were  ignorant  of  the  whole  subject. 

Pathology. — As  regards  the  pathology  of  epileptic  insanity,  it  is,  like 
the  pathology  of  epilepsy,  as  yet  very  obscui'e.  I  have  met  with  innu- 
numerable  brain  lesions  of  almost  every  kind  in  diiferent  cases,  and,  on 
the  other  hand,  I  have  most  carefully  examined  the  brains  of  many 
epileptic  insane  persons,  and  have  found  no  special  lesion  or  abnormality. 
I  have  found  the  following  amongst  other  lesions,  viz.,  spicula  of  bone 
from  the  skull-cap  and  membranes  pressing  into  the  convolutions, 
apoplexies,  destructive  lesions  of  the  brain  of  all  kinds  and  in  all  places, 
embolisms,  fatty  and  otherwise,  adhesions  of  the  pia  mater  to  the  convo- 
lutions, the  marks  of  traumatic  injuries  of  all  kinds  and  in  all  places  of 
the  brain,  unequal  hemispheres,  and  congestion  of  all  sorts  and  in  all 
places.  I  have  tried  my  best  to  confirm  Schroeder  van  der  Kolk's 
observations  as  to  the  medulla  and  pons  being  always  congested  or 
diseased  in  epileptics.  I  have  certainly  failed  to  do  so,  and  do  not 
believe  that  it  is  the  case.  The  general  result  of  my  pathological  obser- 
vations is,  that  any  source  of  irritation  in  a  brain  of  a  certain  quality 
may  cause  epilepsy,  but  that  an  irritation  to  the  motor  area  of  the  convo- 
lutions is  infinitely  more  apt  to  cause  it  than  one  anywhere  else.  The 
coordination  of  the  convulsions,  the  unconsciousness,  and  the  breathing 
difficulties  of  the  actual  fit,  may  arise  in  the  medulla,  but  the  real  origin 
of  the  convulsions  is  usually  higher  up  in  the  brain.  To  have  epilepsy 
we  must  have  an  inherent  motor  instability  in  the  convolutions,  just  as 
we  must  have  essential  mental  instability  in  the  convolutions  in  order  to 
have  insanity.  The  epilepsy  is  an  occasional  dynamical  disturbance, 
that  may  be  the  result  of  a  constant  pathological  lesion,  or  of  an 
inherently  morbid  brain  constitution.  It  is  a  remarkable  fact  in  epilepsy 
that  one  hemisphere  of  the  brain  is  in  nearly  all  cases  found  considerably 
heavier  than  the  other,  and  that  in  by  far  the  majority  of  the  cases  of 
infantile  paralysis  or  unilateral  development,  where  one  hemisphere 
of  the  brain  is  larger  and  more  perfect  than  the  other,  such  patients  are 
subject  to  epileptic  fits. 

Treatment. — As  to  the  general  treatment  of  epileptic  insanity,  it  is 
that  of  epilepsy  with  that  of  mania  superadded ;  and  with  special  pre- 
cautions to  combat  the  special  dangers  I  have  described.  Give  the 
bromides  regularly  and  steadily  as  you  give  food  to  your  epileptics. 
Find  out  the  dose  for  each  case  that  will  saturate  but  will  not  bromize, 
Avhich  will  be  from  forty  to  seventy  grains  a  day  in  different  cases.  Half 
bromide  of  potassium  and  half  of  sodium,  with  one  or  two  minims  of 
liquor  arsenicalis  to  each  dose,  makes  a  capital  combination.  It  can  be 
given  for  years.  I  have  known  it  continued  now  for  fifteen  years  in  a 
case,  with  immense  benefit  and  no  harm  all  that  time.     Some  few  cases 


296  EPILEPTIC    INSANITY. 

will  not  be  benefited  at  all,  but  four-fifths  will  be  so  more  or  less,  and 
one-half  will  be  benefited  very  much,  while  one-fourth  will  be  so  much 
benefited  as  to  be  practically  cured,  so  long  as  they  are  kept  under  treat- 
ment. Its  use  will  very  often  save  epileptics  being  sent  to  asylums.  Any 
physician  to  an  asylum  Avho  does  not  keep  most  of  his  epileptic  patients 
continuously  under  the  influence  of  the  bromides  deliberately  disregards 
one  of  the  best  proved  therapeutic  facts,  for  I  have  proved  by  experiment 
that  he  can  reduce  the  fits  to  one-sixth,  taking  all  the  epileptics  in  an 
asylum  together,  and  practically  cure  some  cases,  while  most  are  improved 
mentally.  Any  physician  out  of  an  asylum  who  has  an  epileptic  to  treat, 
and  sends  him  into  an  asylum  without  trying  the  eifect  of  the  bromides, 
does  not,  I  think,  give  his  patient  the  best  chance  known  to  science. 
Many  patients  will  at  times  become  bromized,  but  the  white  tongue, 
mental  hebetude,  and  slow  muscular  movements  of  this  condition  can  be 
easily  seen  in  time  before  much  harm  is  done.  Intermittent  bromide 
treatment  is  of  little  or  no  use.  It  must  be  continuous  to  do  much  good. 
Why  the  bromide  does  good  to  epileptics  is  as  yet  not  ascertained  in  an 
absolutely  definite  scientific  way ;  but  my  belief,  founded  on  a  most  ex- 
tensive experience  of  its  use,  is  that  its  therapeutic  effects  are  closely 
connected  with  its  physiological  actions  of  (1)  diminishing  the  irritability 
of  nervous  tissue;  (2)  lessening  the  blood-pressure  in  the  capiUaries; 
(3)  diminishing  the  sexual  desire  and  the  reproductive  power;  (4)  pro- 
ducing a  slowness  in  the  mental  operations  allied  to  the  phlegmatic  tem- 
perament. In  addition  to  the  bromide  treatment,  dietetic  regulation,  the 
avoidance  of  surfeits,  plenty  but  not  too  much  exercise,  life  in  the  fresh 
air,  no  excitement  that  can  be  avoided,  and  no  alcohol,  are  all  useful.  I 
have  several  epileptics  who  will  almost  certainly  take  fits  or  become  irri- 
table if  they  go  to  a  dance  or  get  two  glasses  of  whiskey.  Blisterings  and 
setons  do  good  in  some  cases,  while  ergot  and  conium,  especially  if  com- 
bined with  chloral  and  the  bromides,  will  control  outbursts  of  excitement. 

The  moral  treatment  must  be  soothing  but  firm,  with  no  arguing, 
sharpness,  imperiousness,  or  useless  verbal  contradiction.  There  is  a 
procedure  in  the  management  of  cases  of  epileptics  subject  to  maniacal 
attacks  that  I  look  on  as  of  the  greatest  importance  as  tending  to  prevent 
attacks  of  mania  coming  on.  It  is  founded  on  the  natural  history  of  the 
disease.  After  an  epileptic  fit  of  the  graver  kind,  a  patient  is  always 
necessarily  unconscious  at  first,  then  stupid  and  confused,  and  then  sleepy, 
and  if  he  is  favorably  situated  he  goes  off  into  a  very  sound  sleep.  This 
seems  to  me  nature's  mode  of  restoring  the  disturbed  cerebral  circulation 
and  recuperating  the  exhausted  organs.  Even  after  the  sleep,  most  epi- 
leptics feel  tired  for  a  time.  Now,  by  carefully  giving  an  epileptic  the 
chance  of  sleeping  after  his  fits,  by  putting  him  on  a  sofa  and  darkening 
the  room,  we  aid  nature  in  her  efforts  to  get  over  these  effects.  When 
the  patient  will  not  sleep,  but  shows  signs  of  being  restless  and  excitable, 
give  him  twenty  or  thirty  grains  of  chloral,  with  a  drachm  of  the  bromide, 
and  put  him  to  bed  in  a  dark  room.  The  chances  are  he  will  sleep  soundly 
and  long,  and  will  wake  up  all  right.  I  have  seen  this  plan  succeed  in 
apparently  averting  an  outburst  of  epileptic  mania  dozens  of  times. 

As  regards  the  results  of  treatment,  they  are  in  one  way  unsatisfactory 
from  the  risk  of  relapse,  and  in  another  way  satisfactory,  because  the 


EPILEPTIC    INSANITY.  297 

patients  may  go  home  from  asylums  and  earn  their  livelihood,  and  enjoy 
their  liberty  for  long  periods,  often  for  life,  if  they  will  persevere  in  suit- 
able treatment.  A  patient  recovered  from  epileptic  insanity  may,  while 
he  is  well,  be  quite  as  well  as  a  woman  recovered  from  puerperal  insanity. 
Our  results  in  the  Morningside  Asylum  for  the  ten  years  1873—81  have 
been  that  out  of  one  hundred  and  twenty-eight  cases  admitted,  thirty-one, 
or  twenty-four  per  cent.,  have  been  discharged  recovered  of  their  epileptic 
insanity,  and  Avith  the  epilepsy  itself  greatly  modified.  Most  of  these 
have  been  able  to  remain  at  home.  And  it  must  be  remembered  that  the 
cases  sent  to  asj^ums  are  the  worst  cases  of  the  disease.  The  milder 
cases  with  infrequent  attacks  are  often  treated  at  home  very  satisfactorily. 

Local  Prevalence. — Epileptic  insanity  prevails  very  differently  in 
different  parts  of  this  country.  In  the  southern  agricultural  counties  of 
England,  where  wages  are  low,  life  is  stagnant,  food  is  not  too  abundant, 
and  beer  is  almost  universally  used  as  a  part  of  the  dietary,  epileptic 
insanity  is  unusually  common — standing  over  eleven  per  cent,  of  all  the 
admissions,  and  in  some  individual  counties  forming  about  one-fourth  of 
all  the  inmates  in  the  county  asylums  of  those  counties.  This  includes 
the  epileptic  idiocy  and  imbecility,  as  well  as  the  cases  where  the  epilepsy 
arose  later  in  life.  In  such  parts  of  the  country  the  former  kind  of  epi- 
leptic insanity  prevails  much  more  than  the  latter.  In  the  better-off 
mining  and  manufacturing  counties,  such  as  Durham,  Glamorgan,  Staf- 
ford, etc.,  and  in  some  counties  of  mixed  population,  such  as  Sussex,  the 
proportion  of  epileptic  insanity  in  the  admissions  is  only  about  five  per 
cent.  Clinically,  epileptic  insanity  is  more  acute  and  typical  in  those 
districts.  In  the  large  cities  of  England  it  holds  an  intermediate  place, 
forming  about  eight  per  cent,  of  the  admissions  to  the  asylums  of  those 
cities.  In  Scotland  it  prevails  to  a  less  extent  than  in  England.  In  the 
admissions  to  the  Royal  Edinburgh  Asylum,  whose  pauper  patients  are 
drawn  entirely  from  a  city  population,  only  four  per  cent,  have  labored 
under  epileptic  insanity  during  the  past  nine  years,  and  only  seven  per 
cent,  of  our  present  inmates  are  of  this  class.  In  other  parts  of  Scotland 
it  is  still  more  infrequent. 

(The  following  is  the  general  summary  and  conclusions  of  my  experi- 
ments made  in  1867  to  detennine  the  precise  effects  of  the  bromide  of 
potassium  in  epilepsy  and  epileptic  insanity :) 

Twenty-nine  cases  of  epilepsy  of  old  standing,  all  having  the  same  diet,  and  subject 
to  the  same  conditions,  were  subjected  to  systematic  treatment  by  bromide  of  potas- 
sium, after  their  normal  condition  as  to  fits,  weight,  temperature,  general  health,  and 
mental  state  had  been  ascertained  and  noted.  I  gave  them  gradually  increasing  doses 
of  the  medicine,  from  five  grains  up  to  fifty  grains,  three  times  a  day,  and  the  treat- 
ment was  continued  for  thirty-eight  weeks,  every  essential  particular  in  regard  to  the 
disease  and  their  bodily  and  mental  condition  being  noted  every  week  during  that 
time. 

The  total  number  of  fits  taken  by  the  patients  fell  gradually  under  the  use  of  the 
medicine  to  one-sixth  of  their  average  number  without  medicine. 

The  fits  taken  during  the  day  were  lessened  to  about  one-twelfth,  and  those  taken 
during  the  night  to  about  one-third  of  the  previous  number. 

The  reduction  in  the  fits  wa.s  not  uniform  in  all  the  cases.  In  one  ca-e  it  amounted 
to  twenty-four  thousand  per  cent.,  in  one-half  of  them  to  more  than  one  hundred  per 
cent.,  and  in  five  cases  there  was  no  reduction  at  all. 

In  one-fourth  of  the  cases  the  fits  were  much  less  severe,  in  some  being  less  severe, 
while  as  frequent  as  before. 


298  TRAUMATIC    INSANITY. 

In  one-fourth  of  the  cases,  the  patient's  mental  state  was  very  greatly  improved. 
Nervous  and  mental  irritabilitv  and  tendency  to  sudden  violence  were  wonderfully 
diminished  in  those  cases,  and  they  were  the  woret  of  the  patients  in  that  respect. 

Attacks  of  epileptic  mania  were  diminished.  In  some  cases  the  mental  state  was 
improved,  while  the  tits  remained  as  frequent  as  ever. 

The  majority  of  the  patients  gained  considerably  in  weight  while  the  doses  were 
under  thirty-live  grains,  three  times  a  day.  Their  aggregate  weight  was  greater  at 
the  end  of  the  thirty-eight  weeks  than  it  had  been  to  begin  with,  though  it  began  to 
fall  after  thirty-five-grain  doses  had  been  reached. 

The  patients'  average  temperature  fell  somewhat  until  they  got  to  fifty-grain  doses 
thrice  a  day. 

The  pulse  gradually  fell  about  seven  beats  up  to  forty-grain  doses.  After  that  it 
rose,  but  not  up  to  its  usual  standard  without  medicine. 

None  of  the  patients  suftered  in  their  general  health  except  five.  All  the  othei"s 
were  benefited  in  some  way. 

The  ill  effects  produced  by  the  medicine  in  those  five  cases  were  torpor  of  mind  and 
body,  drowsiness,  increase  of  temperature,  loss  of  weight,  loss  of  appetite,  and  in  three 
of  them  slight  double  pneumonia. 

The  cases  most  benefited  by  the  drug  were  very  various  as  to  the  causes,  number, 
and  character  of  the  fits,  age,  and  in  every  other  respect.  On  the  whole,  the  cases 
who  took  most  fits  benefited  most. 

The  cases  in  whom  the  medicine  had  ill  eftects  had  all  taken  fits  from  childhood, 
were  all  very  demented  in  mind,  and  took  more  than  one  fit  per  week,  but  seemed  to 
have  nothing  else  in  common. 

The  diminution  of  the  fits  and  all  the  other  good  effects  of  the  medicine  reached 
their  maximum  in  adults  at  thirty-grain  doses,  three  times  a  day,  while  ill  effects  were 
manifested  when  thirty-flve-grain  doses,  three  times  a  day,  were  reached. 

There  seemed  to  be  no  seriously  ill  effects  produced  in  twenty  of  the  cases  by  fifty- 
grain  doses  of  the  medicine,  thrice  a  day,  continued  for  ten  weeks. 

"When  the  medicine  was  entirely  discontinued  for  a  month  in  all  the  cases,  the 
average  number  of  fits  increased  in  five  of  the  cases  benefited  to  or  beyond  their 
original  number,  in  thirteen  cases  they  remained  considerably  less. 

"The  average  number  during  that  time  was  a  little  more  than  one-half  the  number 
of  fits  taken  before  the  medicine  was  given,  and  the  greatest  number  of  fits  occurred 
in  the  second  week  after  the  medicine  was  discontinued. 


TRAUMATIC   INSANITY. 

A  few  cases  of  mental  disease  are  caused  by  blows  on  the  head,  falls, 
and  other  traumatic  injuries  to  the  brain.  Sunstroke  also  causes  in- 
sanity, and  the  general  mental  symptoms  of  traumatism  and  sunstroke 
are  apt  to  be  alike.  No  doubt,  sunstroke  gets  the  credit  of  far  more 
insanity  than  it  produces.  Few  Englishmen  become  insane  in  hot 
climates,  in  whom  that  cause  is  not  assigned.  My  experience  is  that 
traumatic  insanity  is  to  be  found  in  two  forms.  The  first  form  is  the 
more  characteristic  type  of  the  disease.  It  is  accompanied  by  motor 
symptoms,  either  in  the  shape  of  speech  difficulties,  slight  hemiplegia, 
general  miiscular  weakness,  or  convulsions.  Usually  in  such  cases  there 
are,  in  addition,  sensory  symptoms,  such  as  cephalalgia,  vertigo,  halluci- 
nations, a  feeling  of  confusion  and  incapacity  for  exertion  of  any  kind, 
mental  or  bodily.  The  mental  symptoms  are  usually  a  forai  of  melan- 
cholia at  first,  tending  in  time  towards  an  irritable  and  sometimes  impul- 
sive and  dangerous  dementia  or  delusional  insanity.  In  my  experience, 
such  cases  are  all  absolutely  intolerant  of  alcoholic  stimulants,  a  very 
little  of  which  will  always  make  them  maniacal,  and  often  very  dangerous 
and  even  homicidal.  Many  of  them  have  a  craving  for  stimulants,  too, 
which  they  indulge,  and  which  aggravates  all  these  symptoms.     It  is 


TRAUMATIC    INSANITY.  299 

surprising  what  a  number  of  the  traumatic  cases  are  complicated  with 
alcohol,  in  having  been  addicted  to  drink  before  these  accidents,  or  taking 
to  it  after.  Over  one-half  of  my  cases  were  so  complicated.  In  either 
case,  whether  a  drunkard  falls  and  injures  his  brain  and  becomes  insane, 
or  w^hether  a  man  takes  to  drink  and  becomes  insane  after  an  injury,  the 
alcohol  aggravates  the  mental  symptoms,  and  tends  more  strongly  towards 
incurability  than  mere  uncomplicated  traumatism. 

A  few  cases  become  ordinary  epileptics.  I  have  two  epileptics  in  the 
Royal  Asylum  now"  who  have  large  depressed  fractures,  and  I  have  seen 
several  more  on  the  post-mortem  table.  In  one  there  had  been  a  fracture 
above  the  ear,  where  the  bone,  membranes,  and  brain  all  adhered  by  an 
old  inflammation.  I  have  seen  three  patients  now,  in  Avhom  the  motor 
symptoms  w^ere  so  exactly  those  of  general  paralysis  that  I  diagnosed 
them  as  such,  but  they  turned  out  to  be  non-progressive,  though  not 
curable  paralytic  cases ;  and  now,  after  over  ten  years,  they  are  alive, 
and  no  worse  than  at  first.  One  man,  H.  H.,  fell  oif  a  ladder,  and 
fractured  the  base  of  his  skull,  was  unconscious  for  long,  and  seemed 
afterwards  to  become  a  true  general  paralytic  from  this  cause,  but  his 
symptoms  did  not  progress.  Another,  H.  I.,  a  drunkard,  received  an 
injury  to  his  head,  was  unconscious,  and  seemed  to  become  mentally  and 
bodily  a  most  typical  general  paralytic,  but  the  motor  symptoms  never 
progressed.  As  I  mentioned,  traumatism  is  one  of  the  rare  causes  of  true 
general  paralysis.  I  had  one  such  case  that  was  caused  by  a  railway 
collision,  but  then  the  man,  after  the  accident,  attempted  to  study  and 
enter  a  profession  with  a  weakened  brain  and  an  impaired  memory. 
Within  three  years  he  became  a  general  paralytic,  and  died  of  the  disease. 

Usually  the  motor  symptoms  of  traumatic  insanity  are  non-progressive, 
or  very  slowly  so.  But  they  do  not  always  manifest  themselves  at  once 
after  the  injury.  I  had  one  patient,  H.  L.,  who  was  not  made  uncon- 
scious at  all  by  the  blow  of  a  piece  of  wood  falling  on  his  head,  but  who 
gradually  in  three  months  got  weaker  on  one  side,  as  well  as  being 
muscularly  weak  all  over,  and  also  mentally  impaired  in  memory,  energy, 
and  volitional  power.     He  was  also  very  irritable. 

Certain  very  interesting  cases  have  been  recorded  of  insanity  directly 
following  fractures  of  the  skull,  with  consequent  pressure  on  the  brain, 
which  w^ere  cured  by  trephining  or  raising  the  depressed  bone.  One  of 
the  most  striking  of  these  was  published  by  Dr.  Charles  Skae.^  It  was 
that  of  a  miner  who  received  a  depressed  fracture  of  the  skull  about  three 
inches  above  the  left  extremity  of  the  left  eyelid,  w'as  unconscious  for  four 
days  afterwards,  then  went  to  work,  but  within  a  fortnight  exhibited  a 
change  of  disposition  and  habit.  Instead  of  being  a  sociable,  merry, 
good-natured  man,  fond  of  his  wife  and  children,  he  became  at  first 
irritable,  moody,  unsocial,  and  suspicious,  and  then  excited  and  danger- 
ous, and  then  acutely  maniacal.  He  was  sent  to  the  Ayr  Asylum,  and 
two  months  after  admission,  during  which  time  he  had  not  improved,  an 
operation  was  performed  by  Dr.  Clarke  Wilson,  by  which  the  depressed 
portion  of  bone  was  removed.     A  gradual  improvement  in  mind  took 

^  Journal  of  Mental  Science,  vol.  xix.  p.  552. 


300  TRAUMATIC    INSANITY. 

place  week  by  week  after  this,  until  in  a  short  time  he  was  as  sociable, 
lively,  and  cheerful  as  ever,  and  has  continued  so  ever  since. 

Such  cases  are  very  suggestive  of  thought  and  inquiry  as  to  the  pos- 
sible reflex  and  direct  irritations  that  may  be  the  causes  of  mental  disease 
in  many  cases,  and  they  clearly  show  that  the  dynamical  brain  disturb- 
ance which  we  call  insanity  may  sometimes  originate  in  special  points  of 
local  brain  irritation. 

The  condition  of  the  urine  as  to  sugar  and  albumen  should  be  carefully 
tested  in  all  traumatic  cases.  Where  sugar  exists  there  is  room  for  grave 
suspicion  of  mischief  to  the  pons  near  the  floor  of  the  fourth  ventricle, 
though  this  can  scarcely  be  diagnosed  with  certainty  in  this  way. 

Some  cases  of  idiocy  result  from  injury  to  the  brain  by  the  forceps 
during  delivery,  and  I  have  two  now  in  the  Royal  Asylum  resulting  from 
falls  on  the  head  in  early  childhood. 

The  other  and  less  distinct  class  of  traumatic  cases  are  those  in  whom 
an  injury  to  the  brain  acts  as  an  exciting  cause  of  an  ordinary  attack  of 
insanity  in  a  person  predisposed  to  the  disease — in  fact  where  traumatism 
acts  like  a  moral  shock.  As  the  result  of  a  bout  of  drinking  or  some 
such  disturbing  cause  of  brain  action  after  traumatism,  I  have  seen  attacks 
of  mania  and  melancholia  in  patients  from  which  they  recovered  perfectly ; 
and,  on  the  other  hand,  I  have  now  under  my  care  several  cases  of  ordi- 
nary dementia,  and  one  of  chronic  mania,  and  one  of  delusional  insanity, 
all  incurable,  and  originating  in  traumatism,  but  without  any  motor 
sensory  signs,  and  without  progression  of  symptoms.  I  once  saw  a 
young  man,  H.  M.,  of  nineteen,  who  had  an  attack  of  ordinary  acute 
mania  just  after  being  in  a  railway  accident,  and  presumably  caused  by 
it,  but  by  which  he  had  not  been  made  unconscious,  or  even  stunned. 

I  have  now  a  case  of  suicidal  melancholia,  H.  M.  A.,  aet.  46,  resulting 
directly  from  an  injury  to  his  head  through  a  piece  of  stone  falling  on  it 
from  a  height  of  ten  feet,  and  then  his  falling  twenty  feet  on  the  back  of 
his  head  oft"  the  scaffold  on  which  he  was  working,  cutting  the  skin  over 
the  occiput,  but  neither  injury  causing  prolonged  unconsciousness.  This 
occurred  three  months  ago,  and  ever  since  he  has  been  able  to  do  no  work, 
has  suffered  from  a  dull  feeling  in  his  head  and  much  pain  in  his  back. 
His  mental  condition  became  gradually  depressed.  His  attention  was 
concentrated  on  his  ailments  until  he  was  quite  melancholic.  He  became 
suicidal,  fancied  he  passed  only  blood  from  his  bowels,  which  was  a  de- 
lusion ;  and  that  his  food  did  him  no  good,  he  being  fairly  nourished. 
There  are  no  motor  signs,  and  his  temperature  is  normal,  the  reflexes 
being  also  normal,  but  he  does  not  sleep.  He  gradually  improved  under 
treatment,  until  he  became  well  in  mind  and  body  and  able  for  his  work. 

Prevalence  of  Traumatic  Insanity. — We  have  had  twelve  cases 
of  traumatic  insanity  and  the  insanity  of  sunstroke  sent  to  the  Royal 
Edinburgh  Asylum  in  the  past  nine  years,  which  is  only  one- third  per 
cent,  of  the  admissions.  Accidents  to  the  head  do  not  loom  largely  there- 
fore in  the  production  of  the  insanity  of  the  world. 


LECTUREXII. 

SYPHILITIC  INSANITY— ALCOHOLIC  INSANITY. 

The  mental  as  well  as  the  bodily  symptoms  of  brain  syphilis  have 
attracted  more  attention  on  the  Continent  than  in  this  country,  though 
of  late  years  a  greater  medical  interest  has  been  awakened  here  in  regard 
to  this  subject  by  the  writings  of  Reade,  Buzzard,  Broadhurst,  and  Douse, 
but  above  all  by  those  of  Hutchinson  and  Hughlings  Jackson.  It  is  a 
large  subject,  because  the  functions  affected  are  numerous ;  an  obscure 
subject,  because  the  effects  of  the  disease  are  often  very  slight  and  slow 
in  development,  and  are  multifivrious  in  kind ;  and  is  an  interesting 
subject  to  the  alienist,  because  it  is  a  disease  in  which  the  mental  and 
bodily  symptoms  can  after  death  be  often  directly  connected  with  the 
pathological  lesions  present,  and  because  in  some  cases  the  resources  of 
therapeutics  are  most  powerful  and  direct  in  curing  the  disease.  In 
regard  to  the  frequency  of  syphilitic  affections,  there  is  the  most  extra- 
ordinary difference  of  experiences  among  different  authors.  Douse  makes 
the  astounding  statement  that,  of  ten  thousand  patients  under  his  treat- 
ment at  the  Central  London  Sick  Asylum,  three-fourths  were  the  subjects 
of  acquired  or  hereditary  syphilis.  That  statement  is  enough  to  make 
one  shudder.  Its  import,  if  a  fact,  to  the  mental  and  bodily  future  of 
London  is  appalling.  Whatever  may  be  the  frequency  of  ordinary 
syphilitic  affections,  all  authors  agree  that  brain  syphilis  is  rare,  abso- 
lutely and  relatively.  Dr.  Wilkes  first  pointed  out  "that  when  the 
primary  and  secondary  manifestations  of  syphilis  are  least  marked,  the 
viscera  and  nervous  system  are  affected  in  an  inverse  ratio ;"  that  is,  we 
find  that  in  a  large  number  of  cases  of  brain  syphilis  there  have  been  few 
primary  or  secondary  symptoms,  and  no  traces  of  the  effects  of  the  disease 
in  the  viscera.  My  own  observation  confirms  that  of  others,  that  the 
syphilis  which  ultimately  attacks  the  brain  or  its  membranes,  has  often 
lain  for  many  years  entirely  latent,  or  apparently  so,  before  it  produced 
any  symptoms  at  all.  I  think  there  is  no  doubt  that  a  hereditary  pre- 
disposition towards  the  neuroses  determines  the  effects  of  the  poison 
towards  the  brain.  In  addition,  injury  to  the  brain,  previous  disease, 
venereal  excesses,  over-study,  mental  anxiety  or  worry,  and  even  fright, 
may  all  act  as  determining  causes  of  brain  syphilis.  Lancereaux  states 
that  the  learned  professions  are  especially  liable  to  it. 

Looking  at  the  matter  from  a  purely  pathological  point  of  view, 
"syphilis  of  the  nervous  system,"  though  a  term  often  used,  is,  strictly 
speaking,  a  misnomer,  for  Hughlings  Jackson  has  shown  that  the  poison 
never  really  attacks  the  nerve  tissue  proper  at  all,  but  only  its  neuroglia, 
fibrous  tissue,  bloodvessels,  lymphatics,  membranes,  or  bony  coverings, 
involving  the  nerve  tissue  and  its  functions  secondarily,  by  pressure,  so 


302  SYPHILITIC    INSANITY. 

causing  irritation,  inflammation,  and  ramollissement,  or  by  starvation  from 
deficient  blood-supply,  and  so  causing  degeneration  and  atrophy. 

Brain  syphilis  with  mental  symptoms  is  in  this  unique  position,  that 
in  the  most  characteristic  cases  its  pathology  is  much  more  definite  than 
its  symptoms.  The  pathological  changes  may  involve  any  and  every 
part  of  the  brain,  and  in  any  and  every  degree.  The  symptoms,  there- 
fore, mental  and  bodily,  depend  on  the  position  and  on  the  intensity  of 
the  morbid  process.  We  may  have  the  most  acute  and  delirious  mania 
caused  by  a  rapidly  groAving  destructive  syphiloma  in  the  convolutions, 
or  we  may  have  a  mental  enfeeblement  so  slowly  progressing  that  it 
takes  twenty  years  to  run  its  course,  caused  by  an  obstructive  arteritis 
gradually  closing  up  the  lumen  of  a  few  of  the  cerebral  bloodvessels. 

My  own  experience  would  lead  me  to  classify  syphilitic  insanity  into 
four  forms ;  and  here  I  am  conscious  of  the  disadvantage  I  am  under  in 
having  chiefly  to  do  with  the  mental  symptoms  of  brain  syphilis,  instead 
of  having  to  treat  of  the  whole  subject  as  a  pathological  entity  with  its 
whole  bodily  and  mental  symptoms.  The  brain  syphilis  that  has  bodily 
symptoms  only  I  have  nothing  to  do  with,  though  its  pathology  and 
treatment  may  be  precisely  the  same  as  the  mental  cases,  the  only  differ- 
ence being  the  locus  in  quo.*  The  mere  sketch  I  am  able  to  give  here 
of  the  mental  symptoms  will  by  no  means  exhaust  the  great  variety  of 
psychological  phenomena  met  with  in  this  disease. 

The  first  form  may  be  called  secondary  syphilitic  insanity.  It  occurs 
during  the  second  stage  of  the  disease,  is  coincident  with  the  eruption, 
is  curable  and  rare.  Dr.  Cadell^  has  described  a  typical  case.  A  gentle- 
man contracted  an  infecting  chancre  in  January.  A  squamous  syphilide 
appeared  in  April,  and  along  with  it,  marked  mental  excitement,  and  an 
extreme  amount  of  motor  restlessness,  this  maniacal  state  reaching  its 
height  in  August  and  September,  and  then  almost  amounting  to  delirium. 
"  The  patient  took  no  rest  in  bed,  was  in  the  habit  of  riding  and  driving 
about  recklessly  during  the  night."  This  maniacal  excitement  gradually 
diminished,  until  in  December  the  patient  appeared  to  be  in  his  normal 
mental  state,  this  being  coincident  with  the  gradual  disappearance  of  the 
syphilide.  In  the  following  April,  an  attack  of  mild  suicidal  melan- 
cholia with  "paralysis  of  energy,"  came  on,  and  lasted  for  over  a  year, 
this  being  coincident  with  the  falling  out  of  the  hair  of  the  head,  eye- 
brows, and  beard.  With  the  disappearance  of  all  traces  of  the  syphilis 
and  the  restoration  to  bodily  health,  the  mental  state  also  became  normal 
and  remained  so. 

I  have  now  a  case,  H.  0.,  a  young  woman  of  twenty,  who  seems  to 
have  contracted  syphilis  either  just  before  or  just  after  her  recent  mar- 
riage, and  on  admission  to  the  asylum  showed  the  characteristic  eruption 
of  the  second  stage,  with  sore  throat  and  reduced  condition.  For  eight 
days  before  admission  she  had  been  maniacal,  and  Avhen  sent  here 
was  almost  incoherent,  very  uncivil,  and  foul  in  her  language,  being 
especially  erotic  and  nasty  in  her  ideas.  She  had,  as  well  as  the  syphi- 
litic eruption,  bronchitis,  with  some  amount  of  pleurisy.  She  was  put 
on  iodide  of  potassium,  with  a  little  mercury  and  tonics,  and  nutrients. 

*  Journal  of  Mental  Science,  vol.  xx.  p.  564. 


SYPHILITIC    INSANITY.  303 

She  gradually  improved  in  mind,  the  syphilitic  eruption  passed  away, 
but  her  lung  disease  went  on,  and  of  that  she  died  within  six  months. 

Now,  such  cases  might  be  thought  to  be  mere  coincidences  of  an  attack 
of  mania  with  one  of  syphilis,  were  they  not  too  common  for  this,  and 
were  the  beginning  and  termination  of  both  diseases  not  so  contem- 
poraneous.  I  presume  such  moral  causes  of  insanity  as  fear,  remorse, 
and  shame,  come  in  and  help  the  blood  poison  to  start  the  psychosis  in 
such  cases  sometimes.  But  it  would  be  strange  if  the  infection  of  the 
system  and  of  the  blood  w"ith  such  a  virulent  and  vile  poison  did  not 
sometimes  derange  the  functions  of  the  convolutions  in  persons  predis- 
posed to  insanity.  This  form  of  syphilitic  insanity  has  no  known 
pathology.  Its  treatment  is  that  of  secondary  syphilis,  and  its  prognosis 
is  good. 

The  second  form,  the  delusional  syphilitic  insanity,  is  one  due,  in  my 
opinion,  to  slight  brain  starvation  and  irritation  from  syphilitic  arteritis 
that  has  become  arrested.  It  consists  of  an  incurable  monomania  of 
suspicion  or  of  unseen  agency,  with  hallucinations  of  the  senses,  but 
without  motor  symptoms,  following  at  some  distance  of  time  an  attack 
of  syphilis  in  persons  strongly  predisposed  to  insanity.  It  seems  as  if,  in 
fact,  the  syphilitic  jjoison  had  produced  a  subtile  dynamical  change  in  the 
brain  convolutions  and  their  trophic  energy,  as  well  as  the  arteritis,  mani- 
festing itself  in  unreason,  hallucinations,  and  an  organic  feeling  of  ill- 
being.  Dr.  Hugh  Grainger  Stewart  published  several  graphic  cases  of 
this  kind.  One  of  them  imagined  that  he  underwent  a  kind  of  a  nightly 
torture  called  by  him  the  "cylinder  finish;"  another  said  that  most 
ingenious  machines  were  introduced  into  her  brain  to  torture  her;  another 
that  people  shot  vitriol,  ammonia,  and  "black  poison"  at  him  all  night, 
to  avoid  which  he  wedged  his  bedroom  doors,  covered  the  key-holes  with 
blankets,  stuffed  his  ears  and  nostrils  with  cotton-wool,  and  his  mouth 
with  a  pocket  handkerchief,  all  these  defensive  measures  against  his 
imaginary  bombardment  taking  him  an  hour  to  carry  out  before  he  went 
to  bed.  I  have  several  cases  of  the  same  kind  under  my  care  just  now. 
One  is  a  woman,  H.  P.,  a  prostitute,  who  thinks  there  is  a  network  of 
wires  in  her  brain,  put  there  by  me.  Another,  a  gentleman,  H.  Q., 
strongly  predisposed  to  insanity,  his  only  sister  being  insane,  who,  a 
year  or  two  after  a  bad  attack  of  syphilis,  and  while  some  of  its  consti- 
tutional effects  still  remained,  developed  delusions  of  a  conspiracy  against 
him,  and  that  people  affect  him  sexually  at  night.  Uuder  the  influence 
of  these  delusions  he  became  dangerous.  Such  cases  are,  in  my  experi- 
ence, always  incurable.  They  are  liable  to  be  complicated  by  alcoholic 
and  phthisical  causes  of  brain  disturbance.  I  admit  that  it  may  fairly 
be  asked  about  such  cases — Can  we  not  have  those  symptoms  without 
the  occurrence  of  syphillis  at  all  from  mere  heredity  taking  this  develop 
ment?  I  think  we  can.  Or  is  there  such  proof  in  any  of  those  patients 
that  have  been  syphilitic  that  this  poison  or  its  trophic  effects  were  really 
the  causes  of  the  mental  derangement  ?  In  many  of  them  certainly  the 
time  between  the  supposed  cause  and  its  effects  was  long,  and  altogether 
the  scientific  proof  of  their  connection  is  Aveak.  Still  the  coincidence  of 
this  type  of  case  with  previous  severe  attacks  of  syphilis  is  certainly 
very  marked  in  a  large  number  of  cases.     There  is  a  general  resem- 


304  SYPHILITIC    INSANITY. 

blance  between  the  mental  symptoms  of  such  cases  and  those  of  the  case 
of  "vascular  syphilitic  insanity"  (case  of  H.  S.,  p.  305),  where  actual 
disease  was  found  in  the  arteries  of  the  brain. 

The  next  two  forms  have  a  very  definite  pathology.  One,  the  third 
on  the  list,  may  be  called  the  vascular  sypliilitic  insanity,  and  the  fourth 
the  '■'■  syphilomatous  insanity.''^  The  one  depends  on  the  tendency  of 
the  poison  to  affect  the  bloodvessels  of  the  brain  and  cause  slow  arteritis, 
with  diminished  blood-carrying  capacity  and  consequent  slow  starvation 
of  the  cerebral  tissue.  The  other  depends  on  the  tendency  of  the  poison 
to  affect  the  connective  tissue,  neuroglia,  membranes,  and  bones,  and 
cause  pressure,  irritation  direct  and  reflex,  and  inflammation  in  the  con- 
volutions. Any  other  causes  of  arteritis,  or  tumor,  or  pressure,  or  irrita- 
tion than  syphilis,  would  probably  produce  somewhat  the  same  mental 
symptoms,  and,  as  a  matter  of  fact,  some  of  those  mental  symptoms 
follow  non-specific  arteritis  and  tumors,  and  also  traumatic  lesions  of  the 
brain.  Yet  the  syphilitic  cases,  though  not  absolutely  pathognomonic, 
are  nearly  so  in  most  instances. 

Of  the  vascular  syphilitic  insanity  I  give  the  following  cases  out  of 
many  I  have  met  with,  because  they  are  very  typical :  H.  K.,  when  he 
was  a  student,  was  infected  with  syphilis,  which  ran  a  bad  course,  and 
many  of  its  somatic  effects  never  left  him,  e.g.,  copper-colored  spots  and 
baldness,  and,  as  we  shall  see,  his  liver  was  the  seat  of  an  old  gumma- 
tous deposit.  He  entered  the  church,  married,  and  procreated  several 
unhealthy  children.  In  twelve  years  after  his  attack  of  syphilis  he 
became  changed  mentally  and  morally,  showing  a  morbid  irritability, 
threatening  violence  to  his  wife  and  children,  disregarding  the  decencies 
of  life,  and  the  proprieties  of  his  social  station  and  profession,  going 
about  his  parish  telling  improper  stories,  and  not  conducting  himself 
rightly  in  regard  to  some  of  the  female  members  of  his  congregation. 
On  admission  to  the  asylum,  his  mental  symptoms  Avere  those  of  simple 
coherent  "reasoning  mania."  He  had  stricture,  copper-colored  blotches 
on  his  skin,  and  irregular  baldness.  After  being  in  the  asylum  a  month 
he  aifirmed  he  had  several  "fits,"  but  there  was  no  proof  then  of  con- 
vulsions. He  was  untruthful,  malicious,  showed  no  natural  feeling,  and 
no  self-respect.  He  Avas  a  year  in  this  asylum,  and  was  then  transferred 
to  another.  His  mental  power  steadily  deteriorated;  he  became  subject 
to  regularly  recurring  convulsive  seizures ;  after  some  years  he  had,  along 
with  general  weakness,  a  partial  paralysis  of  the  left  side,  with  incon- 
tinence of  urine,  thickness  but  not  tremulousness  of  speech.  Mentally 
he  passed  from  irritability  into  enfeeblement  and  loss  of  memory;  from 
that  into  stupor,  in  which  state  he  died  thirteen  years  after  he  first 
showed  mental  symptoms,  and  twenty-five  years  after  he  had  contracted 
the  attack  of  syphilis  which  had  been  at  the  root  of  all  his  ills. 

On  post-mortem  examination  the  calvarium  was  found  condensed,  and 
the  right  side  of  the  frontal  bone  thicker  than  the  left.  The  dura  mater 
was  much  thickened,  congested,  and  adherent  to  the  bone  and  to  the  pia 
mater,  and  this  last  to  the  brain  convolutions,  so  that  the  dura  mater 
could  not  be  removed  without  lacerating  the  convolutions.    This  was  par- 

1  Mr.  Hayes  Newington,  Journal  of  Mental  Science,  vol.  xii.  p.  555. 


SYPHILITIC    INSANITY.  305 

ticularly  the  case  over  the  parietal  and  frontal  lobes.  On  section,  a  great 
part  of  the  centre  of  the  anterior  lobe  of  the  right  hemisphere,  and  many 
of  its  convolutions,  were  found  to  be  atrophied,  the  place  of  the  neurine, 
white  and  gray,  being  taken  by  a  flocculent,  gelatinous,  fibrous  material. 
The  outer  layer  of  the  gray  matter  of  those  convolutions  was  found  to 
be  normal  looking.  On  the  left  side  of  the  brain  the  white  matter  was 
generally  lacking  in  consistence — pale  in  some  places  and  congested  in 
others.  The  lining  membranes  of  all  the  ventricles  were  very  granular. 
The  basal  ganglia  on  the  right  side  were  softened  and  congested. 

An  examination  of  the  arteries  of  the  brain  showed  a  hypertrophy  of 
all  the  coats,  causing  extraordinary  obliterations  of  the  lumen  in  places, 
irregular  contractions,  and  nodulated  thickenings.  Every  form  of  irreg- 
ular local  arteritis  was  found,  all  the  vessels  being  more  or  less  affected, 
but  especially  the  branches  of  the  middle  and  anterior  cerebral  passing 
to  the  atrophied  part  of  the  right  hemisphere. 

The  spinal  cord  was  found  to  have  undergone  general  atrophy  with 
anaemic  and  softened  portions  in  the  dorsal  region,  and  intensely  con- 
gested portions  in  the  lumbar  region.  The  dura  mater,  pia  mater,  arach- 
noid, and  cord  were  all  matted  together  in  some  places.  The  liver  was 
found  to  be  puckered  with  cicatrices,  and  to  have  a  small  gummatous 
tumor  the  size  of  a  bean  in  one  portion  of  it. 

It  was  evident  that  here  there  had  been  a  syphilitic  inflammation  of 
the  membranes ;  but  the  great  bulk  of  the  mental  and  bodily  symptoms 
could  be  traced  to  the  effects  of  the  arteritis  causing  first  irritation  in  the 
brain  convolutions  and  then  a  slow  process  of  blood  starvation.  The  real 
character  of  the  case  was  never  diagnosed  during  life. 

In  the  following  case  the  arteritis  seems  to  have  ceased  to  get  worse  at 
a  very  early  period  of  the  disease,  and  its  effects  mental  and  bodily  were 
therefore  almost  stationary  for  thirty -five  years:  H.  S.,^  set.  30  on 
admission.  Patient  had  a  severe  attack  of  syphilis  at  seventeen,  for 
which  he  was  treated  with  mercury.  After  this  he  was  always  irritable, 
and  sometimes  violent.  On  one  occasion  he  attacked  his  mother,  and 
smashed  the  door  of  a  neighbor's  house  with  a  poker,  and,  when  taken 
to  the  police  ofiice,  that  night  had  a  partial  hemiplegic  attack.  He  was 
for  ten  years  in  a  private  asylum  at  Musselburgh,  and  then  was  taken  to 
Morningside.  On  admission,  he  had  delusions  of  suspicion,  impulsive- 
ness, violence,  and  also  hallucinations  of  hearing,  fancying  he  heard 
voices  calling  him  "low,"  "mean,"  and  seeing  figures  that  he  imagined 
jumped  down  his  throat.     He  was  taciturn  and  melancholic,  too. 

In  three  years  his  delusions  were  worse.  He  seemed  to  have  had  a 
slight  difliculty  of  speech,  and  he  imagined  a  woman  had  located  herself 
in  his  mouth  and  was  the  cause  of  this,  as  well  as  of  a  bitter  taste  in  his 
mouth.  His  gait  was  a  little  unsteady,  straddling,  and  ataxic,  and  he 
dragged  one  leg  a  little.  His  bodily  condition  was  never  strong,  and  he 
looked  weary  and  pale,  and  he  always  suffered  more  or  less  from  dys- 
pepsia. His  delusions,  impulsiveness,  and  excessive  irritability  of  temper 
continued  for  the  twenty-six  years  he  lived  in  the  asylum ;  and  superadded 

^  This  case  was  more  fully  reported  by  the  late  Dr.  J.  J.  Brown,  then  assistant  physi- 
cian, Royal  Edinburgh  Asylum,  in  the  Journal  of  Mental  Science,  July,  1875. 

20 


306  SYPHILITIC    INSANITY. 

to  these  there  was  considerable  general  enfeeblement  of  mind.  His  legs 
got  weaker  before  death  in  1875.  He  died  of  diarrhoea.  The  brain 
membranes  were  thickened,  a  thin  layer  of  blood-clot  was  found  under 
the  pia  mater,  and  the  convolutions  were  much  atrophied.  There  was  a 
small  cyst  in  the  pons,  evidently  fi-om  old  apoplexy.  The  microscopic 
appearances  were  the  most  striking  (see  Plate  VIII.,  Figs.  1  and  2). 
The  arteries  in  the  pons  were  thickened,  the  muscular  coats  being  hyper- 
trophied  to  an  enormous  extent,  the  outer  coat  being  also  much  thickened, 
and  in  and  around  this  coat  was  a  molecular  deposit  (Plate  YIII.,  Fig.  1) 
containing  also  granular  masses,  this  deposit  in  many  instances  filling  up 
the  perivascular  space.  At  some  parts  the  vessels  were  patent,  at  others 
completely  occluded,  and  the  lumen  absent,  the  artery  presenting  the 
appearance  of  concentric  rings  in  the  centre  of  a  granular  deposit.  The 
gray  matter  of  the  convolutions  was  found  to  be  degenerated,  the  cells 
being  atrophied,  and  their  spaces  in  many  instances  being  occupied  by  a 
few  granules  (see  Plate  VIII.,  Fig.  2).  The  spinal  cord  was  also  afiected 
in  the  same  way  in  its  arteries,  and  in  its  gray  and  white  substance. 
There  were  many  microscopic  apoplexies  in  the  white  substance  of  the 
cord. 

No  better  demonstration  of  chronic  vascular  disease  of  syphilitic  origin, 
and  its  effects  of  brain  starvation,  degeneration,  and  atrophy,  with  the 
resulting  mental  suspicions,  hallucinations  of  hearing,  and  lack  of  self- 
control,  could  have  been  afforded  than  this  case. 

I  have  seen  some  of  the  most  extraordinary  pathological  effects  in  the 
brain  from  slow  syphilitic  arteritis.  I  have  several  specimens  of  brains 
in  which  the  whole  of  the  white  substance  in  the  inside  of  the  anterior 
and  middle  lobes,  lying  between  the  outside  convolutions  and  the  central 
ganglia,  had  gradually  and  entirely  disappeared,  leaving  a  vacant  space 
filled  with  fluid  and  a  few  fibrous  floccufi.  The  gray  substance  of  the 
convolutions,  looked  at  from  the  inside  in  an  antero-posterior  section  of  a 
hemisphere,  presents  the  most  extraordinarily  defined  appearance,  just  as 
much  so  as  when  looked  at  from  the  outside  (see  Plate  V.).  The  convo- 
lutions looked  as  if  the  white  substance  had  been  carefully  pared  off  them, 
leaving  the  gray  matter  intact.  The  effect  was  exactly  what  would  have 
resulted  had  that  portion  of  brain  been  steeped  in  a  fluid  which  had  the  power 
of  dissolving  away  the  white  substance  and  leaving  the  gray  entire.  The 
cause  of  this  is  no  doubt  the  histological  facts  that  (1)  the  gray  substance 
of  the  convolutions  has  five  times  the  amount  of  capillary  blood-supply 
of  the  white;  and  (2)  the  source  and  mode  of  supply  is  different,  the 
gray  substance  getting  it  from  the  already  divided  and  anastomosing  net- 
work forming  the  pia  mater,  and  the  white  substance  getting  its  supply 
from  single  vessels,  which  in  dividing  form  only  an  infi'equent  anasto- 
mosis, and  a  network  with  large,  long  meshes.  The  white  substance,  in 
fact,  slowly  dies,  and  disappeai-s  through  an  arteritis  which  only  causes 
partial  atrophy,  ansemia,  and  lessened  mental  ftinction  in  the  gray  con- 
volutions. Looking  at  such  a  brain,  many  questions  suggest  themselves. 
How  do  the  convolutions  act  whose  white  fibres  of  communication  inwards 
and  their  interconvolutional  fibres  have  quite  disappeared?  Is  there  a 
general  power  of  conduction  in  the  convolutions  from  one  through  the 
next,  and  so  on  till  it  reaches  one  whose  ingoing  fibres  are  intact  ?     Can 


PLATE     V 


SYPHILITIC    INSANITY.  307 

the  convolutions  still  act  in  some  degree  even  deprived  of  their  projection 
and  association  system  of  white  fibres? 

Most  of  the  vascular  cases  have  the  general  course  of  H.  R.  Mentally 
a  change  of  character,  morbid  suspicions,  loss  of  self-control  and  of  the 
moral  feelings,  a  disregard  of  the  decencies  of  life,  then  an  intense  irri- 
tability, often  with  violence  and  a  loss  of  memory,  then  an  enfeeblement 
of  the  mental  power,  ending  in  complete  dementia.  Bodily,  an  unhealthy 
and  cachectic  general  state,  a  lack  of  trophic  power,  with  no  cephalalgia 
necessarily,  then  a  general  failure  of  muscular  power  and  a  tendency  to 
partial  paralysis,  then  occasional  epileptiform  fits,  sometimes  unilateral, 
but  never  more  localized  than  a  motor  paralysis  that  advances  and  recedes 
in  a  puzzling  way,  then  loss  of  power  over  the  sphincters,  loss  of  trophic 
power,  and  death,  if  that  has  not  occurred  before  through  an  attack  of 
convulsions.  The  duration  is  very  different  in  different  cases,  but  in  my 
experience  it  is  never  less  than  five  years,  and  may  be  twenty-five.  If 
one  was  fortunate  enough  to  be  able  to  diagnose  a  case  in  the  earliest 
stages,  no  doubt  the  iodide  of  potassium,  with  nerve  tonics,, nutrients, 
and  brain  rest,  should  be  prescribed,  and  I  think  I  had  a  case  where  these 
measures  saved  the  patient  from  going  further  than  mild  and  manageable 
childishness,  without  tendency  to  convulsion.  But  if  the  lumen  of  an 
artery  has  been  lessened  by  slow  syphilitic  arteritis,  we  have  no  reason 
to  think  it  can,  by  any  therapeutic  means,  be  made  more  patent ;  and  if 
some  of  the  brain  tissue  has  already  been  starved  into  atrophy,  most 
certainly  it  would  be  a  groundless  hopefulness  to  think  of  its  possible 
restoration. 

Looked  at  purely  from  the  pathological  point  of  view,  the  arteritis  may 
affect  vessels  of  any  and  every  size  down  to  capillaries,  may  thicken  the 
fibrous  or  the  muscular  parts  of  the  arterial  wall,  or  any  of  the  coats. 
It  is  usually  irregular  and  local,  and  often  nodular.  I  do  not  know  any 
more  instructive  demonstration  of  the  visible  effects  of  a  lack  of  blood 
supply  on  brain  cells  and  fibres  than  may  be  found  in  sections  from  dif- 
ferent parts  of  a  brain  affected  by  syphilitic  arteritis  (Plate  VIII.,  Fig.  2). 

The  fourth  or  syphilomatous  form  is  so  exceedingly  various  in  its 
symptoms,  mental  and  bodily,  that  I  really  do  not  know  where  to  begin. 
It  may  consist  of  a  syphilitic  meningitis  attended  with  a  temporary 
stupor  and  delirium,  which  is  most  curable  by  the  iodide  of  potassium. 
Or  it  may  consist  of  a  quick -growing  syphiloma  within  a  convolution,  that 
causes  in  a  few  weeks  extensive  softening,  wild  maniacal  excitement, 
general  convulsions,  and  paralysis,  and  speedy  death ;  the  whole  process 
being  from  the  beginning  absolutely  beyond  the  reach  of  cure,  or  even  of 
alleviation.  Or  it  may  consist  of  local  gummata,  causing  pressure,  local 
convulsions,  mental  irritability,  and  very  slowly  progressive  dementia. 
Or  it  may  consist  of  great  cakes  of  syphilitic  inflammation  and  gummatous 
or  semipurulent  deposit  over  one  or  both  hemispheres,  causing  gradual 
dementia,  and  at  last  coma.  Or  it  may  be  a  membranous  or  bony  tertiary 
lesion  that  has  been  quite  arrested  in  its  growth,  but  has  set  up  what  is 
practically  epilepsy  and  ordinary  epileptic  insanity.  I  shall  just  give  an 
idea  of  the  disease  by  referring  to  a  few  cases.  I  shall  first  illustrate  the 
more  acute  forms  by  the  following  case  of  syphilitic  tumor  of  rapid  growth 
within  the  substance  of  the  brain  : 


308  SYPHILITIC     INSANITY. 

H.  T.,  aet.  26,  a  prostitute,  whose  history  was  not  known  except  that 
she  had  been  deliriously  maniacal,  cephalalgic,  and  had  taken  convulsive 
attacks.  On  admission  to  the  asylum  she  was  vacuous  and  taciturn,  and 
almost  in  a  condition  of  stupor.  Her  pupils  were  unequal,  but  there  was 
no  motor  paralysis  visible.  She  wakened  up  partly,  and  spoke  in  a  slow, 
hesitating  way.  After  being  in  the  asylum  for  a  month,  and  taking 
many  convulsive  attacks  during  that  time,  she  died  suddenly  one  day 
after  such  an  attack.  A  small  gummatous  tumor  was  found  in  the  centre 
of  the  anterior  lobe  of  the  right  side,  involving  one  of  the  frontal  con- 
volutions, and  this  was  surrounded  by  a  great  ring  of  white  softening  and 
brain  anaemia,  and  that  again  by  an  outer  ring  of  congestion.  I  had 
lately  another  case  very  similar  to  this,  H.  U.,  aet.  41,  with  no  ascei'tain- 
able  history  of  syphilis,  but  who  had  had  several  miscarriages.  Her 
uncle  had  been  a  patient  in  the  asylum.  For  a  year  she  had  suffered 
from  intense  cephalalgia,  mostly  on  the  right  side,  passing  to  the  forehead 
and  affecting  her  sight.  For  six  months  she  had  had  fainting  turns,  and 
for  three  weeks  convulsive  attacks.  On  admission  she  was  mentally  con- 
fiised,  complained  of  voices  round  her  bed,  and  talked  wildly  and  inco- 
herently about  things  that  had  no  connection  with  the  questions  asked 
her.  She  began  to  take  convulsions  a  fortnight  after  admission,  and  died 
of  these  in  three  weeks.  I  had  during  life  diagnosed  brain  tumor,  prob- 
ably syphilitic.  After  death  we  found  under  the  dura  mater  several 
hemorrhagic  patches.  The  convolutions  presented  a  flattened  "glazed" 
appearance.  Section  of  the  brain  showed  great  pallor  of  the  white  sub- 
stance of  the  left  hemisphere.  In  the  lower  and  middle  part  of  the  left 
internal  capsule  there  were  two  small  gummatous  tumors,  one  the  size  of 
a  big  bean,  the  other  the  size  of  a  filbert.  They  were  surrounded  by  an 
area  of  loose,  disorganized,  softened  brain  substance,  involving  the  an- 
terior third  of  the  corpus  striatum,  spreading  through  the  temporo- 
sphenoidal  lobe,  the  whole  of  which  was  pulpy.  The  softening  extended 
also  along  the  posterior  horn  of  the  lateral  ventricle.  In  the  right 
hemisphere  there  was  also  an  abnormal  pallor,  but  there  was  no  softening 
except  in  the  posterior  lateral  ventricle,  which  presented  much  the  same 
appearance  in  a  less  degree  as  on  the  left  side.  There  was  no  tumor  or 
deposit  on  the  right  side. 

This  exemplified  what  is  very  commonly  found  in  the  brain,  viz.,  a 
symmetrical  lesion  on  both  sides  of  the  brain  in  exactly  the  same  place. 
My  experience  is  that  vascular  and  atrophic  lesions  of  the  brain,  such  as 
apoplexies,  large  or  capillary  softenings,  and  thrombosis,  are  exceedingly 
apt  to  occur  in  both  hemispheres  in  the  same  places  and  almost  at  the 
same  time.  This  vascular  and  tropho-organic  sympathy  of  the  two 
hemispheres,  extending  to  diseased  conditions,  is  a  most  important  fact 
not  noticed  in  pathological  works,  but  physiologically  and  pathologically 
it  must  be  kept  in  mind  in  brain  study. 

In  both  the  above  cases  the  cerebral  bloodvessels  seemed  normal.  A 
small,  local,  quick -growing  syphiloma  in  the  brain  substance  had  caused 
surrounding  destruction  by  pressure  and  irritation,  setting  up  an  inflam- 
matory process,  and  causing  tissue  death.  The  symptoms  had  been 
cephalalgia,  convulsions,  mania,  confusion,  loss  of  attention  and  memory, 


SYPHILITIC    INSANITY.  309 

and  sudden  death  within  a  short  time.  I  have  since  met  with  two  cases 
of  the  same  kind  of  much  slower  course  and  without  convulsions. 

The  next  example  I  shall  take  of  brain  syphilis  is  one  that  most 
physicians  would  not  be  inclined  to  regard  as  one  of  "insanity"  at  all, 
though,  as  a  matter  of  fact,  the  patient  was  incapacitated  for  work,  con- 
fused and  stupid  in  mind,  and  at  times  delirious.  But,  being  a  clear 
case  of  brain  syphilis  of  a  common  type,  with  mental  symptoms  cured  at 
home  by  appropriate  treatment,  it  is  more  important  to  the  practising 
physician  than  cases  with  more  decided  mental  symptoms. 

H.  v.,  set.  33.  Patient's  mother  had  been  insane  for  a  year,  "  after 
a  fall  on  the  head."  He  had  had  syphilis  six  or  seven  years  ago,  with 
few  secondary  symptoms.  He  had  not  been  feeling  well  for  six  or  seven 
weeks,  suffering  from  very  severe  headaches.  Three  weeks  ago  he  took 
suddenly  a  very  severe  attack  of  general  convulsions  with  unconsciousness. 
Before  that  he  had  on  several  occasions  a  rather  pleasant  momentary 
feeling  of  "  being  in  a  trance,"  and  this  sensation  preceded  the  fit. 
When  taken  home  after  the  fit,  he  was  confused  and  had  severe  cepha- 
lalgia, and  had  slight  left  hemi-paresis.  He  went  to  the  late  Dr.  Begbie, 
who  prescribed  iodide  of  potassium  in  five-grain  doses.  Since  then  he 
had  travelled  about  a  little,  and  tried  to  do  business,  but  could  not  do  so 
properly  on  account  of  loss  of  memory,  lack  of  power  of  attention,  general 
confusion  of  mind,  and  severe  cephalalgia.  When  I  first  saw  him,  he  was 
considerably  paralyzed  in  the  left  side ;  he  had  double  vision,  and  a  loud 
noise  in  the  right  ear ;  he  was  confused,  mentally  depressed,  his  memory 
very  poor ;  he  was  irritable,  wayward,  tending  to  be  violent,  and  difficult 
to  manage.  If  he  had  been  a  poor  man,  he  would  probably  have  been 
sent  to  an  asylum  at  once.  He  suffered  the  most  fearful  cephalalgia, 
especially  at  night,  and  the  slightest  tap,  especially  over  the  right  side  of 
his  brow,  greatly  increased  his  suflFerings.  The  skin  of  the  right  side  of 
his  head  and  face  was  hypergesthetic,  and  his  right  conjunctiva  injected. 
He  could  not  read  or  write.  Pulse  80,  temperature  98.4°.  Appetite 
gone,  tongue  much  furred.  I  put  him  at  once  on  ten-grain  doses  of  the 
iodide  of  potassium,  with  fifteen  grains  of  the  bromide,  and  one-twelfth  of 
a  grain  of  the  bichloride  of  mercury  thrice  a  day,  with  milk  and  potass 
water  alone  for  diet.  For  about  a  week  he  got  no  better,  suffering  the 
most  fearful  agony  in  his  head  at  night,  becoming  delirious,  and  wanting 
to  go  out  at  the  window.  I  tried  chloral  in  twenty-five-grain  doses  re- 
peated every  two  hours,  as  well  as  the  bromides  and  tincture  of  cannabis 
indica,  in  large  and  repeated  doses,  to  dull  the  night  pain  and  procure 
sleep,  but  with  only  very  temporary  relief.  In  the  mornings,  after  those 
medicines,  he  was  always  more  confused  and  irritable,  and  had  no  ap- 
petite. By  far  the  best  thing  I  found  for  easing  the  night  cephalalgia 
and  procuring  sleep  was  to  make  him  lay  his  head  on  a  rubber  bag  of 
almost  unbearably  hot  water.  After  a  week  the  cephalalgia  abated, 
he  got  a  little  more  sleep,  he  became  less  irritable  and  confused  and 
less  frequently  delirious,  and  he  looked  better,  but  the  paralysis  did  not 
improve  for  a  fortnight,  and  then  I  raised  the  dose  of  the  iodide  to  fifteen 
grains  three  times  a  day.  In  three  weeks  the  double  vision  ceased,  and 
he  began  to  walk  and  grasp  better.  The  cephalalgia  became  merely 
paroxysmal,  and  took  the  form  of  neuralgia  of  the  supra-orbital  branches 


810  SYPHILITIC    INSANITY. 

of  the  fifth  nerve.  He  became  less  sensitive  to  tapping  his  head,  his 
tongue  got  clean,  and  his  appetite  so  ravenous  that  I  had  much  difficulty 
in  keeping  him  from  eating  flesh  diet.  In  a  month  he  was  still  further 
improved,  could  walk,  read,  and  dictate  a  little,  and  was  able  to  be  out 
in  the  open  air,  though  any  exertion,  mental  or  physical,  produced  a 
sense  of  intense  exhaustion.  The  noise  he  had  in  his  right  ear  disap- 
peared about  that  time,  and  also  a  feeling  of  cold  on  that  side  of  the  face. 
In  five  weeks  he  was  almost  convalescent,  and  mentally  normal,  though 
he  had  on  two  occasions  the  "trance"  feeling  that  preceded  the  convul- 
sions. In  two  months  he  had  what  was  evidently  a  syphilitic  inflamma- 
tion of  the  periosteum  over  the  mastoid  process  of  the  right  temporal 
bone.  He  omitted  the  iodide  for  a  week  at  my  advice,  but  at  once  he 
began  to  feel  worse  in  all  respects  mentally  and  bodily.  I  then  increased 
the  dose  to  twenty  grains  three  times  a  day.  This  he  took  steadily  for 
two  years  without  showing  a  trace  of  iodism ;  on  the  contrary,  getting 
fat  and  strong,  and  mentally  vigorous.  A  dimness  of  vision  in  the  left 
eye  and  a  tendency  to  pains  and  slight  weakness  in  his  left  side  on  damp 
days,  were  the  last  of  the  symptoms  to  disappear.  After  two  years  I 
finally  stopped  the  iodide,  after  having  several  times  tried  to  do  so  before 
with  bad  results,  and  he  keeps  well  and  fit  for  business,  with  just  a  trace 
of  head  symptoms  at  times. 

This  was  no  doubt  a  case  of  syphilitic  inflammation  and  thickening  of 
the  membranes  of  the  brain  over  the  right  hemisphere,  affecting  the  cor- 
tex of  the  organ  and  its  functions  mental  and  bodily  by  pressure  and 
inflammatory  irritation.  There  was  no  doubt  a  gummatous  deposit  there. 
The  beneficial  effects  of  large  doses  of  the  iodide,  and  the  tolerance  of 
those  doses  for  so  long  after  the  symptoms  had  apparently  disappeared, 
is  the  common  experience  in  these  cases.  The  mental  symptoms  were 
characteristic  in  all  respects.  I  have  had  other  cases  of  this  kind,  not 
put  under  treatment  so  soon,  which  have  gone  on  for  years  partially 
paralyzed,  subject  to  convulsions,  and  at  last  dying.  In  one  such  case 
(H.  U.)  I  found  a  cake  of  gummatous  semipurulent  material  covering  the 
whole  anterior  portion  of  the  vertex,  causing  pressure  on  the  convolutions, 
and  destructive  softening  of  their  outer  layers.  The  calvarium  was  soft, 
eroded,  and  spongy.  In  another  case  still  in  the  asylum  (H.  X.), 
recorded  by  my  then  assistant,  Mr.  Hayes  Newington,^  the  patient  had 
syphilis  when  young — having  a  necrosis  of  a  portion  of  the  left  side  of 
the  osfrontis,  w^hich  healed  up  however.  During  her  married  life  she 
had  four  still-born  children,  and  then  three  living  ones.  At  the  climac- 
teric period  she  began  to  take  epileptic  attacks,  which  have  continued 
periodically  ever  since,  the  convulsions  always  beginning  at  the  right  side. 
She  was  at  first  periodically  maniacal,  with  hallucinations  of  the  senses 
and  severe  pain  in  the  seat  of  the  old  necrosis,  and  she  has  gradually 
become  demented,  with  occasional  exacerbations  of  maniacal  restlessness 
and  talkativeness — in  fact,  she  has  become  an  epileptic  dement.  In  such 
cases,  as  Mr.  Newington  says,  "  there  is  little  doubt  that  syphilization 
stands  as  the  first  link  of  the  chain  of  factors,  and,   of  course,  the 

*  See  Journal  of  Mental  Science,  vol.  xix.  p.  555. 


SYPHILITIC    INSANITY.  311 

insanity  (now  dementia)  may  be  regarded  as  the  last" — that  last  link  not 
being  forged  till  thirty  years  after  the  first. 

In  the  following  case  a  syphilitic  tumor  of  slow  growth  pressed  on  the 
brain,  eroded  the  bone,  and  caused  the  usual  mental  and  bodily  symptoms 
of  brain  tumor  :  H.  Y.,^  get.  47  ;  history  unknown.  He  had  been  a 
wanderer  over  the  earth.  He  had  the  marks  of  syphilitic  disease.  He 
was  depressed,  confused,  irritable,  had  no  memory,  and  his  general 
mental  power  was  enfeebled.  He  was  restless,  with  an  unsteady, 
shuffling  gait,  and  had  vei'tiginous  and  epileptiform  attacks.  His  left 
arm  was  subject  to  involuntary  and  uncontrollable  twitchings,  with  pain  if 
the  arm  was  held  steady ;  slight  left  hemiplegia  in  leg,  with  partial  left 
facial  paralysis.  He  had  slight  anaesthesia  of  left  cheek  and  arm,  shown 
by  his  not  being  able  to  localize  a  pin  prick  there.  When  pricked  in 
left  arm  he  felt  it  in  left  thigh ;  this  pargesthesia,  however,  disappeared  in 
three  or  four  days.  There  was  at  the  summit  of  the  parietal  eminence 
on  the  left  side  of  the  head  a  tender  spot,  which,  when  tapped,  caused 
the  left  leg  to  be  thrown  into  a  state  of  convulsion  and  twitching,  the 
patient  still  remaining  conscious.  He  had  copper-colored  patches  over 
his  body,  and  a  small  tumor  in  right  groin.  He  was  put  on  large  doses 
(twenty  grains  three  times  a  day)  of  iodide  of  potassium,  with  small 
doses  of  the  bichloride  of  mercury,  but  with  no  benefit.  He  died,  a 
month  after  admission,  in  an  epileptiform  attack. 

On  post-mortem  examination  it  was  found  that  there  was  an  erosion 
penetrating  the  skull-cap,  making  a  hole  through  it  of  an  oval  shape, 
nine-sixteenths  inch  long  by  five-sixteenths  inch  broad,  where  the  ten- 
derness had  existed  during  life.  The  dura  mater  was  adherent  round 
this  point,  and  enormously  thickened — being  a  quarter  of  an  inch  thick 
at  some  parts.  I  often  come  across  such  thickenings  of  the  dura  mater 
in  the  bodies  of  the  insane,  and  they  cannot  be  considered  specific.  On 
the  removal  of  the  dura  mater  a  hard  gummatous  tumor  was  seen  in  two 
nodules,  together  about  the  size  of  a  pigeon's  egg.  The  brain  convolu- 
tions round  this  had  been  pressed  so  as  to  cause  some  atrophy  and 
softening.  I  have  never  seen  a  syphilitic  tumor  of  the  brain  where  the 
cerebral  substance  round  it  and  in  contact  with  it  was  sound,  while  I  have 
seen  all  sorts  of  other  tumors,  even  of  large  size,  embedded  in  normal- 
looking  brain  substance.  The  tumor  by  its  pressure  outwards  had 
caused  the  erosion  in  the  skull-cap.  It  involved  chiefly  the  supra-mar- 
ginal convolution,  and  also  to  some  extent  the  ascending  parietal.  The 
angular  gyrus  was  also  involved. 

Out  of  thirty  one  hundred  and  forty-five  cases  of  insanity  of  all  classes 
of  society  admitted  into  the  Royal  Edinburgh  Asylum  during  the  past 
nine  years,  sixteen  have  been  cases  of  syphilitic  insanity,  or  about  one- 
half  per  cent.  Few  of  these  recovered,  or  are  likely  to  recover,  the 
majority  of  the  patients  being  far  advanced  in  their  disease  before 
admission,  with  serious  involvement  of  the  structure  of  the  brain. 

^  Case  reported  in  Journal  of  Mental  Science,  July,  1879,  p.  216. 


812  ALCOHOLIC    INSANITY. 


ALCOHOLIC  INSANITY. 


il  I  do  not  speak  here  of  the  use  of  alcohol  as  a  general  cause  of  all 
ikinds  of  insanity.  J[t  isjinfortunatelj^_the  niQst  common  of  all  the  causes 
J  of  tha-diaeaae,  in  some  caiesJro3ucing^it  (?e  ?io?'c>^4ii-4;>th«irbn5glnginto 
/activity  hereditary  and  acquired  b'rain  weaknesses.  From  fifteen  to 
twenty  per  cent,  of  the  cases  of  mental  disease  may,  taking  the  country 
Ithrough,  be  put  down  to  alcohol  as  a  cause,  wholly  or  in  part.  As  a 
cause  of  insanity  it  is  not  followed  by  constant  results.  Conditions  of 
mental  depression,  of  exaltation,  of  enfeeblement,  of  stupor,  of  morbid 
impulsiveness,  may  all  be  caused  by  it.  General  paralysis,  paralytic 
insanity,  epileptic  insanity,  adolescent  insanity,  and  climacteric  and  senile 
insanities  may  be  due  to  alcohol  as  exciting  causes  of  the  attacks.  When 
so  caused,  we  do  not  call  these  alcoholic  insanity.  I  have  no  time 
to  speak  here  of  those  most  interesting  degenerations  of  individuals  and  of 
races  that  follow  the  excessive  use  of  alcohol.  Two  great  French 
alienists,  MoreP  and  Moreau  de  Tours,^  have  told  us  nearly  all  we 
know  of  that  subject.  They  looked  at  the  insanity  as  one  of  the  effects 
of  evil  conditions  of  life,  of  bad  and  insufficient  foods,  of  the  use  of  all 
sorts  of  neurotics  in  changing  for  the  worse  the  type  of  human  being  in 
the  first  and  in  the  succeeding  generations.  There  are  few  of  the  unfa- 
vorable conditions  of  life  that  by  themselves  cause  more  human  degenera- 
tion than  the  excessive  use  of  alcohol.  Many  of  the  American  Indian 
tribes,  fine  races  to  begin  with,  have  been  simply  killed  off  by  it  in  a  gen- 
eration or  two,  degenerating  in  body  and  mind  all  the  time.  You  are 
aware  of  the  pathological  tissue-degenerations  that  are  caused  or  promoted 
by  it,  the  atheromatous,  the  fatty,  the  cirrhotic  changes  that  take  place 
in  the  vascular,  the  renal,  the  hepatic,  the  glandular,  the  fibrous,  and  the 
nervous  tissues.  Those  are  the  individual  tissue  and  single  organ  damages. 
The  whole  organism  suffers  somatic  and  mental  lowering,  alteration 
of  function  and  of  energizing.  These  degenerations  are  transmitted  from 
generation  to  generation  in  the  same  or  other  forms  by  hereditary  laws,  if 
not  corrected  by  new  and  improved  conditions  of  life.  In  some  individuals 
they  are  mere  potentialities  and  tendencies,  in  others  they  have  assumed 
definite  forms,  and  become  insanity,  idiocy,  stuntedness  of  growth,  ugliness, 
deformity,  deaf-mutism,  sterility,  incapacity  for  high  kinds  of  education, 
immorality,  and  lack  of  general  control.  Those  are  large  general  ques- 
tions, of  the  highest  interest  socially  and  physiologically.  They  often 
become  very  practical  questions  to  medical  men.  Alcoholic  degenerations 
influence  the  type  of  all  ordinary  diseases,  and  they  interfere  much  with 
the  treatment  adopted  for  their  cure.  When  our  profession  becomes,  as 
it  should  be,  and  as  I  have  no  doubt  it  will  in  time  become,  the  guardian 
— by  prophylaxis — of  the  physical  and  mental  well-being  of  the  people, 
and  the  great  source  of  authority  for  the  regulation  of  the  conditions  of 
life,  such  questions  will  come  far  more  to  the  front  than  they  do  at 
present,  and  they  must  then  form  an  important  part  of  medical  study. 

'  Traite  des  Degenerescences  de  I'Espece  Humaine. 
'  La  Psychologie  Morbide. 


ALCOHOLIC    INSANITY.  313 

Meantime  I  have  merely  to  describe  and  illustrate  those  forms  of  mental 
disease,  in  which  alcohol  has  not  only  been  the  cause,  but  has  so  influ- 
enced the  symptoms  that  they  are  in  some  way  special  or  peculiar,  so 
that  the  mental  and  bodily  results  are,  as  it  were,  specific,  and  so  may  be 
called  alcoholic  insanity.  No  agent  that  I  am  aware  of  has  such  dif- 
ferent results  on  different  brains  as  alcohol.  For  that  reason  alcoholic 
insanity  is  not  in  all  cases  of  the  same  kind. 

Acute  Alcoholism. — The  most  typical  alcoholic  insanity  is  Delirium 
Tremens,  or  acute  alcoholism.  That  this  is  described  in  ordinary  text- 
books on  Practice  of  Physic,  and  is  treated  usually  at  home  or  in  general 
hospitals,  and  is  of  short  duration,  does  not  make  it  less  a  true  insanity. 
From  a  symptomatological  point  of  view  it  is  a  typical  excited  or  motor 
melancholia,  characterized  especially  by  hallucinations  of  sight,  fleeting 
delusions  of  all  kinds,  but  especially  delusions  of  suspicion,  suicidal 
feelings,  partial  or  complete  incoherence,  failure  of  memory,  great  con- 
fusion, tendency  to  mistake  identities  ;  in  some  cases  by  unconsciousness, 
and  by  loss  of  power  of  attention.  It  is  the  bodily  symptoms  that  give 
it  its  most  characteristic  features.  The  motor  restlessness  and  the  motor 
tremulousness  combined  are  excessive  and  constant.  In  addition  the 
temperature  is  usually  above  100°,  there  are  paralysis  of  the  appetite  for 
food,  often  sickness,  generally  lack  of  digestive  power  and  assimilation,  a 
rapid  loss  of  body-weight,  and  absolute  sleeplessness.  In  typical  cases, 
and  in  the  first  or  second  attack,  it  runs  a  somewhat  definite  course,  and 
has  a  short  duration  measured  by  days  or  weeks.  Such  cases  are  now 
often  certified  as  insane  and  sent  to  asylums  for  treatment,  and  but  for 
the  idea  connected  with  an  asylum  they  are  best  treated  there.  We  have 
the  means  of  treating  them  more  satisfactorily  there,  according  to  the 
present  ideas  of  treatment,  than  in  a  hospital.  We  have  trained  at- 
tendants, suitable  rooms,  grounds  for  exercise,  and  no  necessity  for  the 
use  of  narcotics  used  merely  to  keep  the  patient  quiet  and  manageable. 
The  patients  often  recover  sooner  with  us  than  in  hospitals,  chiefly 
because  we  can  keep  them  after  the  first  day  or  two  in  the  open  air.  I 
do  not  recommend  patients  suffering  from  acute  alcoholic  insanity  to  be 
sent  to  asylums  if  they  have  money  enough  to  have  good  skilled  attend- 
ance, and  can  be  sent  to  a  lodging  in  the  country  or  outskirts  of  a  town 
after  the  first  few  days,  simply  because  the  notion  of  having  been  in  a 
lunatic  asylum  is  repugnant  to  most  men's  feelings,  and  it  may  be  more 
injurious  to  a  patient  afterwards  than  if  he  had  been  treated  in  a  hospital 
or  at  home.  It  would  be  easy  enough  for  all  large  general  hospitals  to 
have  some  rooms  and  an  exercise  ground  for  the  treatment  of  such  cases. 
The  chief  difiiculty  is  the  expense  of  keeping  a  permanent  staff  of  two 
good  trained  attendants  for  work  that  would  be  only  occasional. 

Here  is  a  good  case  of  acute  alcoholism  sent  to  an  asylum.  J.  A., 
aet.  34.  Has  had  several  attacks  of  the  same  kind  before.  Drinks  in 
bouts,  not  steadily.  Is  of  an  excitable,  sensitive  disposition  naturally. 
Has  been  ill  for  about  a  week,  during  which  he  has  not  slept.  Is  chat- 
tering incoherent  nonsense,  addressing  imaginary  persons  in  short,  snatchy, 
semi-incoherent  sentences.  His  attention  cannot  be  roused  to  attend  to 
the  questions  put  to  him  ;  evidently  has  hallucinations  of  hearing  and  of 
sight.     He  looks  up  at  the  ceiling  and  round  the  walls  as  if  following 


314  ALCOHOLIC    INSANITY. 

some  object  with  his  eyes,  and  turns  and  says,  "Yes,"  "What  is  it?"  etc., 
as  if  in  answer  to  questions  or  remarks.  He  is  very  restless  and  tremu- 
lous, so  that  he  cannot  hold  a  cup  to  his  lips  and  drink  out  of  it  without 
spilling.  The  temperature  is  101°,  pulse  weak  and  quick,  skin  perspiring, 
eyes  sunk,  expression  of  face  haggard  and  almost  vacant,  pupils  dilated 
but  sensitive,  tongue  tremulous  and  coated.  His  articulation  was  markedly 
tremulous,  like  that  of  a  general  paralytic,  only  thicker.  The  reflexes 
were  dull,  and  the  spinal  reflex  action  almost  gone — in  this  last  respect 
diflering  from  nineteen  out  of  twenty  general  parah^tics.  His  general 
strength  was  very  low.  He  was  put  to  bed  and  fed  with  milk,  and 
effervescing  potass  water,  alternated  Avith  beef-tea.  He  was  made  to 
take  those  things  by  attendants  contrary  to  his  inclination.  He  was 
sent  out  to  walk  assisted  by  an  attendant  for  an  hour  the  first  day,  and 
that  night  he  was  fed  every  hour  irrespective  of  his  inclination.  He 
scarcely  slept.  Next  day  he  was  fed  regularly,  and  was  out  in  the  open 
air  most  of  the  day.  His  pulse  got  stronger  and  he  slept  two  hours  that 
night,  and  his  temperature  fell  to  100°.  The  same  treatment  was  adopted 
day  by  day,  and  no  medicine  was  given  him  but  quinine  and  nitro-muriatic 
acid,  which  were  prescribed  after  the  first  two  days.  In  four  days  he  was 
coherent  and  less  tremulous,  and  could  sit  still.  In  a  week  he  was  ra- 
tional, and  in  ten  days  he  was  well,  all  but  the  sense  of  exhaustion. 

Some  cases  do  not  turn  out  so  well.  There  are  five  chief  risks  from 
the  alienist's  point  of  view  that  I  have  met  with.  The  first  is  that  of  the 
brain  passing  from  a  melancholic  mental  condition  into  that  of  stupor  and 
coma.  This  takes  place  in  veiy  bad  cases  that  have  soaked  and  lived  on 
alcohol  for  years.  I  had  a  great,  stout,  flabby -looking  woman,  J.  B., 
once,  whose  case  took  this  course,  and  she  died  in  ten  days.  She  had 
had  alcoholic  convulsions  before  admission,  and  had  been  dosed  with 
opium.  We  found  intense  brain  congestion,  thickening  of  the  mem- 
branes, and  the  outer  layer  of  the  gray  matter  of  the  convolutions  dis- 
eased microscopically,  being  fiill  of  proliferated  nuclei.  The  second  risk 
is  the  persistence  of  the  hallucinations  of  hearing  after  most  of  the  other 
symptoms  have  gone.  This  is  apt  to  occur  where  there  have  been  many 
previous  attacks,  and  a  neurotic  heredity.  The  treatment  is  exercise  in 
the  open  air  and  mental  distraction  from  morbid  fancies.  Most  of  them 
will  so  recover  in  a  month  or  two.  The  third  risk  is  the  persistence  or 
aggravation  of  the  insane  suspicions  of  poisoning,  of  conspiracy,  or  of 
being  worked  on  by  electricity  and  unseen  agency.  In  fact,  the  case 
becomes  one  of  delusional  insanity.  This  is  very  common,  especially  the 
delusion  of  poisoning.  This  arises  out  of  a  misinterpreted  sensation. 
There  is  chronic  gastritis  or  indigestion  from  alcoholic  irritation  of  the 
mucous  membrane  of  the  stomach,  and  the  patient  attributes  his  bad 
sensations  to  poison.  I  had  one  man,  J.  C,  who  retained  for  years  the 
delusion  that  I  had  put  rats  inside  him,  but  he  recovered  through  proper 
regimen  and  abstinence.  Such  cases,  as  well  as  those  with  the  persistent 
hallucinations  of  hearing,  are  frequently  very  suicidal,  and  need  care  and 
watching  on  that  account.  The  subject  of  the  danger  of  suicide  in  all 
kinds  of  alcoholic  insanity  has  not  been  at  all  sufficiently  dwelt  on.  I 
believe  that  more  suicides,  and  combined  suicides  and  homicides,  result 
in  the  country  from  alcoholism  in  its  early  stages  than  from  any  other 


ALCOHOLIC    INSANITY.  315 

cause  whatsoever.  The  fourth  risk  is  that  the  man's  brain  and  the  man 
himself  gets  out  of  the  attack  with  the  finer  points  of  his  moral  character 
and  feeling  rubbed  oif.  He  is  mentally  different  from  his  former  self, 
though  not  insane.  He  is  more  untruthful  and  unfeeling,  coarser  in  the 
grain,  more  lazy,  and  less  honorable.  His  brain  has  undergone  an  or- 
ganic change  to  some  extent.  Instead  of  fine  membranes,  they  are  milky 
and  thickened ;  instead  of  pure  brain  substance,  it  is  mixed  with  pro- 
liferated neuroglia  and  adventitious  tissue.  The  fifth  risk  is  run  in 
patients  who  have  a  heredity  to  insanity,  and  who  have  frequently  had 
alcoholic  insanity.  Instead  of  the  attack  resolving  itself  in  the  natural 
way,  it  runs  into  an  attack  of  ordinary  melancholia  or  mania,  which  ends 
in  dementia.  In  fact,  there  are  few  cases  that  pass  into  dementia  at  once 
out  of  the  attack  of  acute  alcoholic  insanity,  or  even  without  this — a  de- 
mentia characterized  chiefly  by  a  loss  of  memory,  a  listlessness  and  in- 
action, and  yet  a  coherence  and  apparent  power  of  reasoning  not  seen  to 
be  unreal  till  you  test  them.  Such  cases  have  been  soakers  for  years. 
I  have  one  such  gentleman  now,  J.  D.,  who  once  had  a  powerful  intel- 
lectual brain,  well  stored  with  literature  and  professional  knowledge. 
He  drank  steadily  for  over  twenty  years,  and  then  had  an  attack  of  alco- 
holism, with  symptoms  of  kidney  degeneration  and  hepatic  cirrhosis.  He 
now  talks  very  rationally,  dilates  on  the  cruelty  of  his  being  in  an  asylum, 
and  on  his  being  ruined  by  being  kept  from  his  business.  He  has  no  de- 
lusions, and,  if  you  give  him  the  cue,  will  repeat  half  a  play  of  Shakes- 
peare's, and  tell  you  all  that  occurred  to  him  twenty  years  ago ;  but 
when  you  ask  him  the  day  of  the  week,  or  what  he  had  for  breakfast,  he 
cannot  tell  you  in  the  least.  When  I  say  to  him  (and  this  has  been  my 
stock  answer  to  his  complaints  of  improper  detention  for  ten  years), 

"Well,  Mr. ,  write  to  the  commissioners  and  state  your  case," 

he  will  reply,  "  I'll  do  so  at  once ;  there  never  was  such  an  outrage  com- 
mitted on  a  man  before."  Yet,  in  ten  years,  he  has  never  written  to  the 
commissioners,  though  a  lawyer.  He  wanders  lazily  about  our  grounds, 
of  which  he  has  the  parole,  day  by  day,  and  is  always  happy  in  a  negative 
way,  except  during  the  few  minutes  he  dilates  to  me  on  the  frightful 
cruelty  of  his  being  in  an  asylum.  I  had  another  such  case,  who  could 
not,  for  a  long  time,  remember  his  own  name.  His  brain  had  to  be  re- 
educated to  this  simple  act  of  memory.  Such  patients  are  usually  fat 
and  torpid  in  movement.  They  have  lost  the  fine  lines  and  movements 
of  facial  expression.  Their  affective  nature  is  dulled  or  twisted.  They 
often  have  lost  the  craving  for  stimulants  in  this  state. 

Chronic  Alcoholism. — The  next  form  of  alcoholic  insanity  is  that 
condition  commonly  known  as  chronic  alcoholism.  This  is  also  always 
accompanied  by  motor  signs,  many  cases  indeed  not  being  techrtically 
"insane."  It  is  often  ushered  in  by  alcoholic  convulsions.  A  long- 
continued,  steady  soaking  in  alcohol  is,  I  believe,  much  more  damaging 
to  the  brain  in  its  mental,  motor,  and  trophic  functions  than  bouts  of 
heavy  drinking  with  intermissions  of  sobriety.  In  chronic  alcoholism, 
looked  at,  as  I  am  doing,  chiefly  from  the  mental  point  of  view,  all  the 
symptoms  are  less  acute  and  last  longer  than  those  of  acute  alcoholic 
insanity.  The  suspicions  and  fears  of  the  latter  become  a  chronic  symp- 
tom, the  delusions  are  less  numerous  and  more  apt  to  become  fixed. 


816  ALCOHOLIC    INSANITY, 

The  hallucinations  of  sight  are  absent,  but  we  are  far  more  apt  to  have 
hallucinations  of  hearing.  There  is  loss  of  inhibitory  power,  and  there- 
fore tendencies  to  impulsive  acts.  There  is  sleeplessness,  but  it  is  not  so 
absolute.  There  is  motor  incoordination,  but  not  so  much  restlessness. 
The  speech  is  thick  and  often  tremulous ;  the  tongue  very  quivering  and 
incoordinated  in  its  movements.  The  functions  of  the  cord  are  affected, 
causing  a  slightly  ataxic  walk  and  an  abolition  of  the  spinal  reflexes,  and 
sometimes  of  the  tendon  reflex.  The  temperature  is  usually  about  99°. 
The  appetite  is  never  keen,  and  the  taste  often  perverted,  so  that  the 
patient  complains  of  food  not  being  what  it  professes  to  be. 

Here  is  a  typical  case,  J.  E.,  aet.  41,  an  innkeeper,  whose  brother 
committed  suicide,  and  who  has  drank  hard  for  many  years — whiskey  being 
his  liquor.  His  present  attack  began  with  sleeplessness,  and  restlessness, 
insane  suspicions,  and  hallucinations  of  hearing.  He  thought  his  wife 
poisoned  his  food  and  kept  men  in  the  house,  whom  he  would  go  and 
seek  at  all  hours  of  the  day  and  night  in  cupboards.  When  sent  to  the 
asylum  (he  attempted  suicide  on  the  way)  he  was  almost  sleepless,  heard 
voices  all  about  him  saying  he  was  to  be  destroyed  and  punished,  and 
the  voices  of  his  wife  and  family,  llis  temperature  was  98°.  He  was 
tremulous  and  shaky,  and  could  not  walk  far.  He  could  not  write  or 
drink  out  of  a  tumbler  without  spilling  the  contents  on  the  floor.  His 
tongue  was  foul,  and  very  tremulous — he  could  scarcely  put  it  out  at  all. 
His  appetite  was  gone,  and  he  afiirmed  that  the  meat  we  gave  him  was  the 
flesh  of  his  children;  he  was  put  on  the  bromide  of  potassium  and  steel, 
was  fed  with  liquid  custards,  which  contained  six  pints  of  milk  and  ten 
eggs  a  day,  in  addition  to  some  solid  food.  He  was  taken  out  to  walk 
in  the  open  air  till  he  was  tired  three  times  a  day,  and  he  had  a  constant 
attendant  by  day  and  night  to  prevent  him  doing  any  harm  to  himself 
or  others.  Several  times,  without  any  warning  and  with  no  provocation, 
he  has  rushed  at  and  broke  windows,  struck  attendants,  upset  tables 
covered  with  dishes  and  jumped  into  our  pond.  He  never  could  tell, 
after  doing  them,  why  he  did  these  things.  After  three  months'  treat- 
ment he  was  scarcely  any  better.  He  would  not  read,  or  play  games,  or 
take  any  interest  in  anything,  or  speak  to  anyone  except  when  spoken  to. 
But  in  six  months  he  is  now  much  improved,  and  showing  signs  of 
recovery,  which  I  do  not  expect  to  be  perfect  however. 

In  such  cases  recovery  is  slow,  and  is  very  apt  to  be  incomplete,  if  it 
occurs  at  all.  A  chronic  degeneration  of  the  whole  of  the  brain  plasma 
has  begun.  The  intellectual  power,  the  power  of  application,  origina- 
tion, and  independent  energizing  are  weakened ;  the  delusions  of  suspi- 
cion are  apt  to  persist ;  the  morals  and  self-respect  are  apt  to  be  regained ; 
lying,  stealing,  and  cowardice  are  indulged  in.  The  affection  for  wife 
and  children  is  impaired.  These  symptoms  run  on  for  a  year  or  two, 
and  then  we  have  dementia  supervening.  But  this  termination  is  not 
invariable.  First  attacks  are  often  recovered  from  in  a  way,  even  second 
attacks  will  be  got  over,  but  third  and  fourth  attacks  seldom  completely. 
Instead  of  dementia,  we  have  sometimes  in  young  subjects  delusional 
insanity  supervening.  I  have  one  such  man,  with  a  tremulous  tongue 
that  he  always  put  out  to  one  side,  who  affirms  he  is  "  worked  only  by 
electricity,"  and  hears  voices;  another  who  says  his  food  is  poisoned ; 


ALCOHOLIC    INSANITY.  317 

another  who  thinks  everyone  near  him  insults  him  in  everything  done ; 
another  whose  ribs  are  broken  every  night  by  unseen  enemies.  All  these 
delusions,  you  see,  arc  misinterpreted  sensations. 

The  treatment  of  such  cases  consists  in  the  use  of  tonics  of  all  sorts,  of 
nerve  stimulants  such  as  strychnine,  and  the  continued  current  for  a  time, 
and  especially  of  rigid  abstinence  from  alcoholic  stimulants  and  the  lead- 
ing of  a  controlled,  regular  physiological  life  in  the  open  air,  with  garden 
work  if  possible. 

Mania  a  Potu. — There  is  a  third  kind  of  alcohdic  insanity  of  short 
duration,  but  great  acuteness  while  it  lasts,  called  variously  mania  a  potu, 
or  very  expressively  delirium  ebriosum.  It  occurs  in  the  cases  of 
persons,  often  young,  with  unstable  brains  hereditarily.  It  takes  very 
little  drink  to  produce  it ;  and  in  many  cases  looks  like  a  prolongation 
and  exaggeration  of  that  wild  drunkenness  which  occurs  in  certain  people 
who  are  said  not  to  "carry  their  liquor  well."  A  few  glasses  of  spirits 
make  them  riotous  and  unmanageable,  and  often  quite  delirious,  uncon- 
scious, and  violent.  Such  brains  have  often  shown  a  weakness  from  the 
beginning,  such  as  lack  of  self-control,  tendencies  to  be  -easily  led  away 
into  vice,  incapacity  for  getting  on.  In  some  of  them  there  exists 
a  craving  for  stimulants,  constituting  the  condition  known  as  dipsomania. 
Mr.  Hayes  Newington,  while  one  of  the  assistant  physicians  here,  gave  a 
capital  account  of  mania  a  potu,  with  clinical  illustrations. 

Dipsomania. — I  have  already  treated  of  this  condition  in  the  lecture 
on  conditions  of  defective  inhibition  (p.  250). 

Alcoholic  Degeneration. — Lastly,  I  shall  simply  refer  to  the 
lowered  mental  condition  that  is  apt  to  result  from  the  too  great  indul- 
gence in  alcohol,  apart  from  technical  insanity,  or  from  an  inordinate 
craving,  or  even  from  the  notion  of  disease,  bodily  or  mental,  at  all.  A 
doctor  of  experience  soon  comes  to  observe  in  his  patients  and  in  his 
acquaintances  a  certain  kind  of  change,  mental,  moral,  and  bodily,  in 
the  people  who  habitually  "take  more  than  is  good  for  them."  The 
expression  of  face  and  eyes  is  seen  to  be  changed,  the  mental  tone  to  be 
lowered,  the  power  of  application  to  be  lessened,  the  self-control  to 
be  weakened.  I  am  safe  in  saying  that  no  man  indulges  for  ten  years 
continuously  in  more  alcohol  than  is  good  for  him,  even  though  he  Avas 
never  drunk  all  that  time,  without  being  psychologically  changed  for  the 
worse.  And  if  the  habit  goes  on  after  forty,  the  change  is  apt  to  be 
faster  and  more  decided.  We  see  it  in  our  friends,  and  we  know  what 
the  end  of  it  will  be,  but  we  cannot  lay  hold  on  anything  in  particular. 
Their  fortunes  and  work  suffer,  and  yet  you  dare  not  say  they  are 
drunkards,  for  they  are  not.  It  all  depends  on  the  original  inherent 
strength  of  the  brain  how  long  the  downward  course  takes.  Usually 
some  intercurrent  disease  or  tissue  degeneration  cuts  off  the  man  before 
he  has  a  chance  of  getting  old.  I  have  seen  such  a  man  simply  pass 
into  senile  dementia  before  he  was  an  old  man,  from  mild,  respectable 
alcoholic  excess,  without  any  alcoholism  or  preliminary  outburst  at  all. 
And  I  am  sure  I  have  seen  strong  brains  in  our  profession,  at  the  bar, 
and  in  business,  break  down  from  chronic  alcoholic  excess  without  their 
owners  ever  having  been  once  drunk. 


318  ALCOHOLIC    INSANITY. 

I  have  seen  many  cases  of  insanity  resulting  from  opium-eating,  and 
one  from  the  hypodermic  use  of  morphia.  They  were  very  like  the 
insanity  of  chronic  alcoholism,  but  not  so  suicidal,  with  greater  weakness 
of  the  heart's  action,  and  more  sleeplessness,  sickness,  and  intolerance  of 
food  for  the  first  fortnight.  It  is  precisely  the  same  class  of  persons  who 
indulge  in  opium  who  indulge  to  excess  in  alcohol,  and  the  treatment  is 
the  same,  viz.,  an  immediate  stoppage  of  the  drug,  with  much  liquid 
nourishment,  fresh  air,  and  watching.  I  have  seen  two  cases  of  insanity 
brought  on  by  the  use  of  chloral.  They,  too,  were  of  the  same  generic 
type  as  the  alcoholic  cases,  and  demanded  the  same  treatment. 


LECTURE    XIII. 

RHEUMATIC  AND  CHOREIC  INSANITIES— GOUTY  INSANITY- 
PHTHISICAL  INSANITY. 

The  first  two  varieties  of  mental  disease  may  be  conveniently  studied 
together.  There  can  be  no  doubt  now  entertained  as  to  the  close  connec- 
tion between  chorea  and  rheumatism  ;  as  we  shall  see,  this  connection  is 
shown  very  vividly  in  rheumatic  insanity,  which  is  also  an  acute  choreic 
insanity.  Cerebro-spinal  rheumatism  has  long  been  known,  but  in  some 
of  its  types  it  does  not  come  within  the  scope  of  a  book  on  mental 
disease.  In  one  variety,  however,  the  most  prominent  symptoms  are  an 
acute  delirious  mania  and  choreic  muscular  movements  of  a  violent  char- 
acter. The  ordinary  course  of  an  attack  of  rheumatic  insanity  is  seen 
in  the  following  case  in  a  typical  form. 

J.  F.,  admitted  January  17,  1870,  set.  24,  married.  First  attack  of 
insanity.  Mother  died  of  consumption.  Father  alive  and  well,  and  no 
relative  insane  or  rheumatic.  In  health  she  was  of  a  reserved  and  quiet 
but  nervous  disposition,  steady  respectable  habits,  and  fond  of  her  chil- 
dren. The  predisposing  cause  of  her  illness  seemed  to  have  been  an 
accumulation  of  debilitating  and  depressing  influences,  viz.,  ill-usage  by 
her  husband,  poverty,  cold,  hard  work,  with  insuflBcient  food  during  the 
three  years  since  she  was  married,  and  having  nursed  her  second  child  for 
fifteen  months  up  to  the  period  of  her  attack.  These  things  caused 
a  certain  amount  of  depression*  of  spirits.  The  exciting  cause  of  her 
malady  was  an  attack  of  rheumatism,  not  of  a  very  acute  character, 
which  had  lasted  for  two  months  before  she  became  insane.  She  had 
pains  in  the  back  of  her  neck,  pains  and  much  swelling  of  fingers,  hands, 
feet,  and  legs,  and  some  feverishness ;  but  she  was  never  so  bad  as  to  be 
quite  confined  to  bed.  A  week  before  admission  she  suddenly  ceased  to 
complain  of  her  rheumatic  pains,  and  simultaneously  with  this  relief  she 
showed  signs  of  mental  derangement,  and  violent  chorea  of  head,  arms, 
and  legs  commenced.  Her  first  mental  symptoms  were  a  sort  of  absence 
of  mind  and  inattention  to  what  was  passing  around  her,  taking  no  notice 
of  questions  put  to  her  or  of  her  children.  Before  being  sent  to  the 
asylum,  in  addition  to  this  mental  inattention,  there  was  great  excitement. 
She  tore  her  clothes,  and  tried  to  jump  out  of  a  second-story  window  into 
the  street.  She  was  quite  sleepless,  and  the  choreic  movements  had 
increased  greatly  in  intensity.  Her  limbs  were  never  still  a  moment,  and 
she  threw  her  whole  body  about. 

She  was  much  excited  on  admission,  her  memory  almost  gone,  and 
with  difiiculty  can  be  got  to  speak  at  all  in  answer  to  questions,  but  talks 
incoherently  in  monosyllables  about  the  doctor  who  had  attended  her. 
The  only  question  she  can  be  got  to  answer  is  to  tell  her  name.     The 


320  RHEUMATIC    INSANITY. 

existence  of  delusions  could  not  be  ascertained.  She  is  a  dark-complex- 
ioned woman  Avith  black  hair ;  rather  thin,  muscles  flabby.  Eyes  dark- 
brown  and  sparkling  feverishly,  pupils  contracted,  equal  in  size.  There 
are  very  violent  choreic  movements  of  the  muscles  of  her  face,  head, 
arms,  and  legs.  Anything  she  attempts  to  say  or  do  voluntarily  is 
accompanied  by  extravagant  grimaces,  twitchings,  and  contortions. 
Reflex  action  is  diminished.  Cannot  articulate  more  than  single  words 
at  a  time,  and  those  imperfectly.  Cannot  stand  or  walk,  and  was 
carried  with  great  difiiculty ;  no  tenderness  of  spine ;  lungs  normal, 
respirations  twenty  per  minute;  heart  beating  quickly  but  regularly,  no 
cardiac  murmur.  Pulse  108,  strong.  Tongue  clean  and  moist;  will  not 
take  food.  Urine  clear,  acid,  sp.  gr.  1015 ;  no  albumen  or  deposits. 
Has  not  menstruated  since  beginning  of  last  pregnancy.  Temperature 
100.4°.  Several  bruises  on  body,  especially  over  right  buttock.  She 
was  carried  to  bed  and  ordered  beef-tea  and  some  brandy.  She  did  not 
sleep,  and  on  the  following  day  the  choreic  movements  of  the  legs  ceased, 
the  legs  became  quite  paralyzed  and  nearly  devoid  of  common  sensibility, 
the  reflex  action  in  them  being  absent.  Bladder  paralyzed,  the  urine 
having  to  be  drawn  off"  once,  after  which  she  could  pass  it.  Muscles  of 
eyelids  and  eyes  quite  under  control.  Not  so  the  tongue,  which  she  can 
scarcely  put  out  at  all,  and  then  with  a  jerk  to  one  side.  Mental  excite- 
ment abated,  and  speaks  better.  M.  T.  99.4°,  E.  T.  99.6°,  M.  P.  80, 
E.  P.  84.  Takes  liquid  food ;  eight  ounces  of  wine,  strong  beef-tea,  and 
extra  diet.  She  improved  slowly  until  on  the  23d  January  (six  days 
after  admission)  her  state  was  as  follows :  "  Chorea  much  less  severe, 
complains  of  pain  in  the  knees,  evidently  of  a  nervous  kind,  for  pressure 
slowly  and  carefully  made  does  not  increase  it.  Common  sensibility 
somewhat  exaggerated  in  legs,  and  some  power  of  voluntary  movement 
has  returned  to  them,  but  she  has  little  reflex  movement.  Takes  food 
well,  bowels  regular,  no  sweating,  mentally  confused,  depressed,  no 
memory,  suspicious,  will  not  believe  a  word  said  to  her,  wonders  where 
she  is  and  how  she  came  here.  M.  T.  98.4°,  E.  T.  99°,  M.  P.  108, 
E.  P.  100." 

24^7i  Jan. — To-day  twitching  of  fingers  only,  except  when  she 
attempts  any  voluntary  movements.  More  power  of  voluntary  movement 
in  left  leg  than  right,  which  is  almost  paralyzed.  Right  knee  slightly 
swollen.  Reflex  movement  slight,  and  more  active  in  left  than  right  leg. 
Tongue  twitches  when  put  out,  and  goes  towards  right  side.  Temperature 
the  same.  She  has  hallucinations  of  sight  and  touch,  saying  that  she 
sees  an  old  woman  coming  behind  her  and  eating  her  food,  so  that 
she  cannot  get  any  of  it,  and  that  one  foot  has  been  cut  off".  Is  depressed, 
weeps  and  groans. 

29^A  Jan. — Has  had  a  relapse  ;  chorea  worse  in  left  arm  ;  complains 
of  pains  in  arms  and  legs.  Complains  of  a  burning  feeling  all  over  her. 
A  large  slough  forming  in  right  buttock  where  it  had  been  bruised.  She 
complains  much  of  the  pain  of  this.  She  still  cannot  tell  correctly  the 
place  touched  on  her  legs,  but  when  pinched  she  screams.  Requires  to 
be  fed  with  a  spoon,  shows  an  aversion  to  food,  though  she  is  evidently 
hungry.  M.  T.  100°,  E.  T.  97°,  M.  P.  116,  E.  P.  116.  She  has  no 
affection  of  sight,  and  no  sparks  or  motes  before  her  eyes. 


RHEUMATIC    INSANITY.  321 

bih  Feh. — She  now  has  so  far  recovered  the  power  of  her  legs  that  she 
can  stand.  Chorea  almost  gone  when  she  makes  no  voluntary  move- 
ments. Mentally  a  mixture  of  stupor  and  depression,  as  before,  and  the 
hallucinations  of  sight  and  touch  remain.  M.  T,  99.8°,  E.  T.  101°,  M. 
P.  120,  E.  P.  120. 

She  gradually  improved,  and  her  temperature  fell  until,  on  the  19th 
February,  she  was  reported  as  having  only  very  slight  chorea  in  hands, 
but  as  still  complaining  of  the  pains  in  legs.  Mentally  she  was  still 
confused,  but  her  memory  was  returning.  M.  T.  98.2°,  E.  T.  98°,  M. 
P.  94,  E.  P.  100. 

She  did  not  progress  quite  steadily,  for  on  the  23d  February  her  M,  T. 
was  99.2°,  E.  T.  99°,  M.  P.  100,  E.  P.  108,  and  she  was  some  days 
worse  with  the  chorea  than  others ;  but  yet  she  was  so  far  improved  as  to 
be,  on  the  15th  March,  out  of  bed  nearly  all  day,  able  to  walk,  but  the 
reflex  action  was  much  impaired  in  legs,  and  the  left  hand  partially  par- 
alyzed, and  she  had  the  sensation  as  if  she  did  not  feel  the  ground  under 
her  feet.  Tongue  now  is  simply  unsteady  when  put  out.  Mentally  less 
depressed,  but  still  confused;  very  sceptical  and  much  inclined  to  hide 
herself  from  observation;  fancies  she  is  watched.  Temperature  down  to 
97.8°  in  the  morning.     Is  one  hundred  and  twen^ty  pounds  in  weight. 

2d  April. — "  Believes  now  what  she  is  told,  and  is  almost  rational ; 
but  her  right  hand  is  swollen,  though  quite  painless.  Chorea  rather 
worse,  and  she  cannot  sleep  so  well  as  usual."  The  sleeplessness  in- 
creased, and  tbe  choreic  movements  began  to  trouble  her  exceedingly  at 
night,  and  on  the  4th  her  M.  T.  was  99.2°,  and  her  pulse  104  and  weak. 
As  an  experiment  I  gave  her  twenty  grains  of  chloral  in  the  morning, 
which  made  her  slightly  drowsy,  and  quite  stopped  the  choreic  movements 
till  the  evening,  when  they  came  on  again,  and  she  could  not  sleep.  I 
then  gave  her  forty  grains  of  chloral.  She  slept  soundly ;  the  chorea 
ceased ;  her  temperature  the  next  morning  was  97.3°,  and  the  pulse  84 
and  stronger.  Her  mind  had  not  been  affected  during  this  little  aggrava- 
tion of  the  chorea.  The  swelling  of  the  hand  remained  for  a  day  or  two 
longer,  and  then  gradually  disappeared.  Still  the  reflex  action  in  foot 
was  diminished,  and  she  complained  of  intense  heat  of  hands.  Wound 
on  buttock  healed  up  slowly. 

22(i  April. — No  chorea  now  except  when  she  smiles ;  she  then  grins 
and  looks  nervous  in  her  movements.  Sleeps  and  eats  well.  Industrious 
and  rational.  Has  only  gained  two  pounds  in  weight  in  a  month.  M.  T. 
98.4°,  E.  T.  98°,  M.  P.  96,  E.  P.  84. 

Her  recollection  of  the  coming  on  of  the  disease  is  imperfect,  and  she 
has  no  remembrance  of  the  choreic  movements  beginning.  Her  mind 
must  have  been  affected  quite  simultaneously  with  their  appearance  or 
before  them.  She  does  not  even  recollect  the  rheumatic  pains  going 
away.  She  says  that  she  had  no  conscious  feeling  of  weakness  or  ex- 
haustion frjm  the  nursing  before  the  rheumatism  beo;an.  Her  recollec- 
tion  of  events  which  occurred  during  the  first  month  of  her  illness  is  very 
imperfect. 

29^A  April. — During  the  past  week  has  gained  five  pounds  in  weight, 
and  is  now  cheerful,  rational,  and  says  she  feels  perfectly  well.     Muscles 

21 


322  RHEUMATIC    INSANITY. 

under  her  control.  From  that  time  her  recovery  was  steady  and  rapid, 
till  she  was  well  in  mind  and  body. 

Is  any  light  thrown  on  the  relations  between  rheumatism,  chorea,  and 
insanity,  or  on  the  connection  between  motor  and  psychical  abnormality, 
by  the  case  I  have  related?  Was  the  rheumatism  the  true  cause  of  the 
mental  symptoms,  of  the  chorea,  or  of  both  ?  Were  these  abnormal 
affections  of  motion  and  the  perverted  psychical  manifestations  the  result 
of  an  identical  and  simultaneous  lesion  affecting  both  the  motor  and 
mental  ganglia  ?  Or  was  the  one  dependent  on  the  other,  secondary  to 
it,  or  sympathetic  with  it  ?  Is  it  not  evident  that  in  this  case  we  have  a 
distinct  form  of  insanity,  a  form  about  which  much  may  be  ascertained 
by  a  careful  study  of  its  relation  to,  and  its  correlation  with,  the  motor 
symptoms  ?  It  will  be  observed  that  nearly  all  the  functions  of  the 
nervous  system  were  here  affected — the  nutrition,  heat  production,  motion, 
sensation,  reflex  action,  the  special  senses,  the  memory,  and  the  intellec- 
tual processes  all  at  the  same  time,  and  they  recovered  their  normal  action 
about  the  same  time. 

I  think  it  cannot  be  doubted  by  anyone  that  the  rheumatism  was  the 
true  cause  both  of  the  chorea  and  the  insanity  in  this  case.  All  the 
symptoms — the  coming  on  of  the  disease,  the  choreic  movements,  the 
paralysis  of  motor  power,  the  deadening  of  reflex  action  of  the  legs,  the 
hallucinations  of  sight,  touch,  and  taste,  the  want  of  memory,  the  acute 
delirium  with  unconsciousness  of  anything  going  on  around,  succeeded 
by  confusion  of  ideas,  suspiciousness,  and  sluggishness  of  mind,  the  high 
temperature  increased  at  night,  the/ tendency  to  improvement  in  all  the 
symptoms  coincidently  with  the  lowering  of  the  temperature,  and  the 
slowness  of  the  convalescence — all  these  things  show  that  some  lesion  of 
the  central  nervous  system  existed.  And  when  this  is  taken  along  with 
the  fact  that  such  a  train  of  symptoms  suddenly  appeared  in  the  course 
of  an  attack  of  rheumatism,  that  the  symptoms  of  the  articular  rheuma- 
tism at  once  disappeared,  while  the  fever  did  not  do  so,  and  that  in  this 
woman,  when  she  was  nearly  well,  rheumatic  swelling  of  the  knuckles  of 
one  hand  appeared  along  with  aggravated  choreic  movements,  sleepless- 
ness, and  an  increase  of  temperature,  we  have  very  strong  data,  not  only 
to  conclude  that  rheumatism  was  the  cause  of  the  nervous  and  mental 
symptoms,  but  that  here  we  have  a  true  and  typical  example  of  a  rheu- 
matic insanity,  which  must  be  classed  by  itself  as  a  special  form  of  mental 
disease — a  true  pathological  entity. 

As  to  how  the  nervous  system  was  affected,  may  we  not  form  a  prob- 
able hypothesis  ?  We  know  how  rheumatic  disease,  whatever  it  is,  affects 
the  other  tissues.  We  know  also  something  of  the  kind  of  lesions  of  the 
spinal  cord  which  are  needed  to  produce  paraplegia  and  the  total  absence 
of  the  power  of  the  reflex  action,  even  if  we  do  not  know  fully  the 
pathology  of  chorea  or  of  insanity.  In  regard  to  the  motor  affection  of 
the  legs,  we  saw  that  at  first  there  was  violent  choreic  movement,  which 
was  succeeded  by  complete  paralysis  of  motion,  no  power  of  reflex  move- 
ment, and  greatly  diminished  common  sensibility.  As  the  power  of 
motion  returned,  which  was  in  the  course  of  a  few  days,  there  were 
hypersesthesia  and  a  sensation  of  heat.  Does  not  this  sequence  of 
phenomena  indicate  a  serious  but  transitory  interference  with  the  func- 


RHEUMATIC    INSANITY.  323 

tions  of  the  nerve-cells  and  fibres  in  the  spinal  cord,  such  as  might  be 
produced  by  slight  rheumatic  inflammation  and  infiltration  of  the  con- 
nective tissue  of  the  cord,  causing  pressure  on  the  nerve  elements  ?  If 
the  nerve-cells  or  fibres  had  been  themselves  attacked  with  any  inflam- 
matory affection,  they  would  not  have  so  soon  regained  their  function. 
We  know  the  rheumatic  poison  has  a  special  tendency  to  affect  the 
connective  tissue.  The  rheumatic  pains  in  the  limbs  are  caused,  we 
cannot  doubt,  largely  by  simple  pressure  on  the  small  nerves.  And  if 
the  cord  was  affected  in  this  way,  is  it  not  probable  that  the  same  thing 
took  place  in  the  brain  centres  that  minister  to  special  sensation,  and  also 
in  the  mental  portions  of  the  organ  ?  The  raised  temperature  and  the 
strongly  acid  urine  remained  the  same,  whether  the  rheumatic  inflamma- 
tion was  in  the  joints  or  in  the  central  nervous  system.  But  when  the 
inflammation  had  passed  away,  the  effects  w^ere  far  longer  visible  in  the 
delicate  tissue  of  the  nervous  centres. 

In  this  case  the  insanity  might  be  described  as  a  metastatic  one,  if 
such  a  term  were  strictly  applicable  to  the  effects  of  a  poison  in  the  blood 
whose  effects  are  first  seen  in  one  set  of  tissues,  and  then  in  another  set. 
The  slight  relapse,  when  the  hand  and  the  spinal  cord  were  both  affected 
at  the  same  time,  showed,  however,  that  the  effects  of  the  toxic  agent 
need  not  be  absolutely  limited  to  one  sort  of  tissue.  If  we  believe  this 
theory,  that  of  embolism  falls  to  the  ground,  as  an  explanation  of  the 
chorea  of  rheumatism  with  or  without  mental  symptoms.  There  was  no 
ascertainable  trace  of  a  tendency  to  heart  disease  in  the  case.  The  effects 
of  embolism  could  not  have  so  soon  passed  away,  even  if  it  is  conceivable 
that  it  could  have  been  universal  in  all  parts  of  the  brain  and  cord. 

It  would  seem  that  in  such  a  lesion  of  the  spinal  cord  as  occurred  in 
this  case,  the  common  sensibility  was  the  last  to  be  abolished  and  the  first 
to  come  again ;  then  the  voluntary  motor  power  returned,  then  the  reflex 
actioD,  and,  last  of  all,  the  power  of  the  nerves  which  preside  over  nutri- 
tion. That  the  sensory  and  motor  functions  should  have  been  less  inter- 
fered with  than  the  reflex  action  is  what  might  have  been  expected,  when 
we  consider  that  the  greater  number  of  the  nerve-fibres  ministering  to  the 
two  former  merely  pass  through  the  cord,  while  the  nerve-cells  forming 
the  ganglia  which  subserve  the  latter  function,  lie  in  the  cord  itself.  The 
cord  was  evidently  more  aff'ected  than  the  brain. 

It  was  not  until  all  the  other  functions  were  restored  that  the  trophic 
function  was  restored,  and  the  patient  gained  in  weight  rapidly.  The 
slough  that  formed  over  the  buttock  from  the  bruise,  and  the  slow  healing 
of  the  wound,  showed  how  much  it  was  affected  at  first.  In  regard  to 
the  special  senses,  sight  was  first  aflfected,  and  then  taste,  and  they  were 
restored  in  inverse  order.  Of  the  purely  psychical  functions,  memory 
and  the  power  of  voluntary  attention  were  first  affected,  then  the  coher- 
ence and  balance  of  the  mental  powers  were  upset,  and  lastly  the  whole 
of  the  mental  operations  were  merged  in  the  acute  delirium  and  utter 
incoherence  present.  Curiously,  in  all  the  patients  laboring  under  this 
disease  that  I  have  seen,  there  were  suspicions  of  those  about  them,  and 
entire  scepticism  as  to  what  they  were  told  about  the  most  simple  matters 
during  convalescence.  Yet  there  was  never  in  either  of  them  any  ten- 
dency to  mistake  the  identity  of  anyone  about  them,  and  one  of  the  very 


824  RHEUMATIC    INSANITY. 

first  mental  acts  they  performed  correctly  was  to  take  notice  of  persons 
about  them,  and  know  them  again  when  they  saw  them.  The  healthy 
elasticity  of  mind  and  enjoyment  of  life,  which  is  the  most  certain  proof 
that  the  brain  is  performing  all  its  functions  normally,  was  the  last  to 
return,  and  corresponded  to  the  restoration  of  function  of  the  centres  of 
nutrition,  and  the  commencement  of  a  rapid  increase  in  weight  of  the 
whole  body. 

That  was  the  first  case  of  rheumatic  insanity  I  ever  met  with,  and  it 
has  been  the  best ;  but  I  have  met  with  many  cases  of  the  same  type 
since.  One  had  an  attack  of  chorea  in  youth,  previously  suifered  from, 
though  without  rheumatic  symptoms.  I  had  one  woman  in  whom  the 
disease  was  very  severe,  and  ended  in  complete  paraplegia  and  death  in 
a  few  months.  I  found  the  cord  to  have  undergone  a  destructive  in- 
flammation and  softening  in  all  its  columns  pretty  nearly  throughout  its 
entire  length. 

The  treatment  of  such  cases  is  just  the  treatment  of  acute  rheumatism, 
with  the  nursing  and  care  suitable  for  a  bad  delirious  kind  of  mania  in 
addition.  The  prognosis  is  favorable  in  most  cases.  On  the  whole,  the 
disease  is  rare. 

We  may  have  a  choreic  insanity  both  in  early  youth — the  common 
time  for  chorea — and  in  more  advanced  life  without  any  acute  rheumatic 
symptoms.  The  delirium  is  then,  as  Maudsley  points  out,  of  an  inco- 
ordinated,  jerky  kind,  like  the  muscular  movements.  Such  a  delirium 
is  apt  to  come  in  bursts,  and  to  pass  away  quickly.  In  the  cases  of 
chronic  chorea  the  mental  affection  is  often  depression  at  first,  then  mania 
with  impulsive  acts  of  violence  or  suicide,  and  then  dementia  in  the  end. 
Some  of  these  cases  are  very  sad  from  the  sufiierings — mental  and  physical 
— the  patients  undergo  through  their  involuntary  jactitations.  I  had  a 
man,  J.  G.,  who  frequently  had  to  be  placed  in  a  padded  room  to  protect 
him  from  the  bruisings  he  would  otherwise  have  inflicted  on  himself.  He 
at  last  literally  wore  himself  out.  One  is  justified  in  keeping  such  cases 
under  the  influence  of  chloral  and  the  bromides  to  decrease  their  sufferings. 
Sleep  in  any  form,  and  induced  by  any  means,  is  to  them  a  blessing,  for 
it  is  the  only  time  they  are  at  rest  and  peace. 

In  many  forms  of  insanity  there  are  choreiform  movements  that  cannot 
be  called  ideo-motor.  I  had  a  case  of  general  paralysis,  J.  H.,  in  which 
the  patient's  left  hand  was  always  engaged  in  a  rhythmical  rubbing  of 
his  trousers  with  his  thumb  and  forefinger.  I  have  now  a  case,  J.  J.,  of 
chronic  delusional  mania,  in  which  the  fingers  of  one  hand  are  rubbed 
over  the  thumb  of  the  other  so  constantly  in  a  rhythmical  way  that  the 
cutis  of  both  hands  is  quite  horny ;  and,  like  cases  of  ordinary  chorea,  if 
the  patient  is  held  still  by  muscular  force,  the  subjective  mental  sensation 
is  one  of  pain,  which  soon  shows  itself  in  outward  acts.  I  had  a  case 
of  chronic  mania,  J.  K.,  a  shoemaker,  who,  during  all  his  waking  hours, 
in  church  or  at  a  dance,  except  when  really  shoemaking,  went  through 
the  motor  pantomime  of  pulling  his  threads  through  the  leather.  I  have 
now  a  case  of  excited  melancholia,  J.  L.,  a  lady,  who  makes  the  most 
extraordinary  choreiform  faces  and  grimaces  in  a  sort  of  automatic,  un- 
thinking way.     She  says  it  is  a  relief  to  her  to  do  so.     This  sort  of  move- 


GOUTY    INSANITY.  325 

ment  is  common  among  the  insane,  and  I  look  on  it  as  being  in  many  of 
them  closely  allied  to  chorea. 

The  treatment  of  all  kinds  of  choreic  insanity  is,  first,  tonic  and  nutri- 
tive, and  then  anti-rheumatic.  I  have  had  one  or  two  cases  where  arsenic 
worked  wonders.  I  have  had  other  cases  where  the  bromides  given  as 
for  epilepsy  did  good.  Iron,  too,  and  zinc,  and  the  valerianates,  are  all 
good  in  some  cases.  Cold  to  the  spine  in  certain  cases  temporarily  stops 
the  movements. 

In  the  Middle  Ages  there  used  to  be  Avonderful  epidemics  of  St.  Vitus's 
dance,  with  mental  symptoms  that  were  certainly  morbid,  affecting  at  the 
same  time  thousands  of  persons  by  a  kind  of  morbid  sympathy  and  imita- 
tion. Mankind  seems  less  subject  to  these  strange  imitative,  uncon- 
trollable, mental-motor  epidemics  now  than  it  was  several  hundreds  of 
years  ago. 

GOUTY  OR  PODAGROUS  INSANITY. 

This  is  a  rare  disease  in  forms  sufiiciently  marked  to  come  under 
specialist  treatment,  or  to  be  regarded  as  technically  mental  disease ;  but 
mental  phenomena  due  to  gout  are  common  enough,  and  have  been 
described  by  all  authors  on  the  subject.  Irritability,  incapacity  for 
mental  exertion,  and  depression  are  the  most  common  of  these.  Syden- 
ham gives  a  good  description  of  them  in  his  classic  work  on  gout.  "  The 
body  is  not  the  only  sufferer,  and  the  dependent  condition  of  the  patient 
is  not  his  worst  misfortune.  The  mind  suffers  with  the  body,  and  which 
suffers  most  it  is  hard  to  say.  So  much  do  the  mind  and  reason  lose 
energy,  as  energy  is  lost  by  the  body — so  susceptible  and  vacillating  is 
the  temper — such  a  trouble  is  the  patient  to  others  as  well  as  to  himself — 
that  a  fit  of  gout  is  a  fit  of  bad  temper."  The  above,  no  doubt,  is  the 
most  common  mental  effect  of  gout,  but  it  does  not  amount  to  mental 
disease.  Deep  melancholia  is  a  common  accompaniment  of  the  gouty 
diathesis,  especially  about  the  climacteric  and  early  part  of  the  senile 
periods.  I  have  had  several  cases  of  intense  suicidal  melancholia  at  this 
period  of  life  in  patients  with  a  strong  gouty  heredity  and  gouty  deposits, 
but  who  had  not  been  subject  to  the  regular  acute  attacks.  I  have  one 
such  case  now,  J.  M.,  aged  fifty -five,  with  a  strongly  gouty  heredity  and 
acquired  syphilis,  who  was  always  more  or  less  dyspeptic,  and  suffered 
from  constipation.  He  always  had  marked  psoriasis,  and  latterly  gouty 
deposits  on  lobes  of  ears.  Before  he  became  affected  in  mind  he  fell  off 
in  flesh,  his  skin  eruption  disappeared,  he  became  very  costive,  and  a 
very  dilated  sigmoid  flexure  was  found  to  exist.  Sleeplessness  and  strong 
suicidal  impulses,  with  delusions  as  to  his  trouble,  were  the  chief  charac- 
teristics of  his  depression,  his  reasoning  power  otherwise  being  good. 
Every  kind  of  medical  treatment — anti-gouty,  anti-syphilitic,  soporific, 
sedative,  and  tonic — was  tried  in  vain.  Nothing  really  seemed  to  do  him 
good  except  feeding,  with  an  excess  of  milk  and  eggs,  sugar  and  fresh  vege- 
tables, given  at  first  by  the  nose-tube,  and  living  out  in  the  fresh  air.  He 
got  fat  and  his  sleep  returned  in  about  nine  months,  the  acute  misery  dis- 
appearing, and  I  am  not  without  hope  of  a  recovery  of  an  incomplete  kind. 
He  gained  two  stone  in  weight  under  treatment — a  great  nutritive  triumph 


326  PHTHISICAL    INSANITY. 

in  such  a  subject.  There  are  signs  of  slight  degenerative  tissue  changes 
in  him  in  the  nerves  or  nervous  centres,  or  both,  evidenced  by  a  partial 
paralysis  of  the  ring  and  little  fingers  of  the  left  hand,  with  wasting  of 
the  muscles.  That  of  course  I  do  not  expect  to  disappear.  Garrod  de- 
scribes "gouty  mania"  as  a  very  acute  delirious  affection,  occurring  in 
some  patients  immediately  after  the  cessation  of  the  acute  joint  affections. 
Along  with  the  mania  there  are  heat  of  head  and  fever.  In  one  such  case 
which  he  describes,  all  the  mental  symptoms  passed  off  when  one  toe 
became  affected  in  the  ordinary  way.  This  kind  of  acute  gouty  insanity 
either  terminates  quickly  in  recovery,  or  runs  on  to  congestion  and  in- 
flammation of  the  membranes  of  the  brain. 


PHTHISICAL   INSANITY. 

An  anaemic  brain,  from  whatever  cause,  is  always  prone  to  disturbance 
of  function.  Lack  of  blood  means  imperfect  nourishment.  Where  we 
have  so  vascular  a  tissue  as  the  gray  substance  of  the  brain  convolutions 
(almost  half  composed  of  capillaries),  there  the  blood  is  needed  in  largest 
amount  and  richest  quality  if  we  are  to  have  healthy  and  vigorous  men- 
talization.  Every  one  who  has  experienced  any  disease  that  has  thinned 
and  lessened  the  blood,  has  felt  the  difference  in  his  mental  power  then 
as  compared  with  health.  The  physiological  effects  of  depriving  the 
brain  of  part  of  its  blood,  or  even  of  lowering  the  blood  pressure  down 
to  a  certain  amount,  are  different  in  different  cases  to  some  extent.  In 
this  as  in  other  ways  in  human  beings,  the  strong  and  the  weak  hereditary 
qualities  of  a  brain  come  out.  One  man  merely  has  singing  in  his  ears, 
a  tendency  to  faintness,  or  a  profound  mental  lassitude  and  paralysis  of 
volition,  amounting  almost  to  torpor ;  those  being  probably  the  purely 
physiological  mental  results  of  a  bloodless  brain.  Another  man  becomes 
intensely  supersensitive  and  over-excitable,  suffering  torture  from  sounds 
and  circumstances  that  in  health  would  have  been  calmly  borne ;  another 
cannot  sleep ;  another  has  hallucinations  of  the  senses ;  another  takes 
convulsions,  long  before  that  amount  of  blood  is  lost  that  necessarily 
causes  convulsions ;  and  another  becomes  delirious,  or  is  attacked  with 
insanity.  The  same,  or  rather  far  greater  differences  of  brain  symptoms, 
result  from  the  diseases  and  morbid  conditions  that  cause  or  are  specially 
accompanied  by  anaemia.  The  cachexise,  the  blood-poisonings,  and  the 
diseases  of  nutrition  in  which  blood  is  not  made  in  sufficient  quantity, 
may  all  be  attended  with  danger  to  some  brain  functions,  though  certain 
brains  seem  to  have  the  innate  trophic  energy  to  nourish  their  tissues  and 
perform  their  functions  on  less  blood  than  others.  In  those  predisposed 
by  heredity  to  disturbance  or  enfeeblement  of  the  mental  functions,  it  is 
the  mind  that  suffers  in  conditions  of  bloodlessness.  We  are  entitled  to 
assume  that  the  convolutions  of  such  brains  have  less  than  the  normal 
trophic  and  functional  energy.  After  death,  in  such  cases,  the  whole 
brain,  but  more  especially  the  convolutions  of  the  anterior  lobes  and  the 
vertex,  are  often  found  disproportionately  anaemic  as  compared  with 
the  other  organs  of  the  body  ;  and  the  brain  is  not  only  found  anaemic, 
but  manifestly  wanting  in  normal  consistence,  in  some  cases  atrophied  to 


PHTHISICAL    INSANITY.  327 

some  extent,  and  in  others  presenting  an  appearance  closely  resembling 
the  first  stage  of  necrosis  from  brain  embolism.  In  all  such  cases  its 
specific  gravity  is  lessened.  Chemical  analysis  of  the  brain  has  not  as 
yet  reached  that  point  of  certainty  that  it  can  tell  us  what  constituents 
are  specially  wanting  in  such  diseased  conditions.  In  patients  that  have 
been  insane,  and  had  pulmonary  consumption,  I  have  seen  the  most 
marked  brain  anaemia,  low  brain  specific  gravity,  irregular  vascularity, 
and  soft  brain  texture  that  I  have  met  with,  not  being  cases  of  ''  white 
softening  "  from  embolism  or  other  local  cause  of  brain  starvation. 

The  frequent  association  of  the  depraved  nutritive  condition  known  as 
"scrofulous"  with  idiocy  and  congenital  imbecility  is  well  known  and 
universally  recognized  by  those  who  have  had  experience  of  such  cases. 
The  common  occurrence  of  pulmonary  phthisis  as  a  cause  of  death 
among  the  insane  had  been  long  noted  by  those  having  charge  of  the 
older  lunatic  asylums.  A  special  connection  between  the  scrofulous  and 
phthisical  constitutions  and  the  insane  predisposition  had  been  pointed 
out  by  Van  der  Kolk  and  others.  The  short  attacks  of  delirium  to 
which  some  phthisical  patients  are  subject  had  been  described  by  Morel. 
And  that  mild  unreason,  the  spes  phthisica,  had  been  known  from 
classic  times.  But  any  special  manifestation  of  mental  disorder  directly 
connected  with  pulmonary  consumption  had  not  been  described  till  in 
1863  I  did  so,  as  the  result  of  a  very  careful  statistical  inquiry  into  the 
matter.  I  was  led  to  the  conclusion  that  such  a  connection  existed  on 
clinical  grounds  as  well  as  statistical  ;^  hence  I  called  the  form  of  mental 
disease  Phthisical  Insanity.  This  is  not  the  place  to  combat  the  argu- 
ments that  have  been  put  forward  against  the  existence  of  this  mental 
disorder.  No  doubt  consumption  was  startlingly  more  frequent  as  a 
cause  of  death  among  the  inmates  of  the  older  asylums  than  in  the 
modern  institutions ;  but  still  it  is  in  all  asylums  for  the  insane  between 
three  and  four  times  more  common  than  in  the  general  population  at  the 
same  ages.  In  the  Royal  Edinburgh  Asylum  it  has  fallen  almost  to  one- 
half  in  the  past  ten  years  under  improved  hygienic  conditions  compared 
with  the  period  of  1842-1861.  But  that  has  nothing  to  do  with  the 
two  per  cent,  of  my  patients  that  I  classify  on  admission  as  phthisical 
insanity  on  account  of  their  mental  and  bodily  peculiarities,  which 
I  shall  presently  describe. 

No  doubt  brain  anaemias  of  all  kinds,  and  from  whatever  causes,  are 
apt  to  produce  mental  conditions  like  phthisical  insanity,  and  in  some 
individual  cases,  I  admit,  quite  indistinguishable  from  it.  It  is  said 
that  insanity  is  infrequent  in  hospitals  for  consumption.  It  may  be  that 
such  mental  disturbance  as  would  be  properly  reckoned  technical  insanity 
is  not  common  in  such  institutions,  but,  so  far  as  I  am  aware,  we  have  no 
statistics  on  that  question.  We  have  only  one  person  in  every  twenty- 
one  hundred  of  the  general  population  becoming  insane  every  year ;  and 
if  one  in  every  thousand  of  the  persons  already  phthisical  became 
insane,  that  would  not  bulk  largely  in  the  mind  of  a  physician  to  a  hos- 
pital for  consumption  whose  attention  was  not  directed  to  the  matter, 
though  it  would  be  an  increase  of  insanity  of  one  hundred  per  cent. 

1  Journal  of  Mental  Science,  April,  1863. 


328  PHTHISICAL    INSANITY. 

But  the  great  reason  why  insanity  is  not  common  in  hospitals  for 
consumption  is  simply  that  it  usually  appears  before  the  lung  symptoms 
of  the  phthisis,  and  the  cases  are  sent  to  lunatic  asylums  instead. 

I  have  the  satisfaction  of  knowing  that  many  acute  clinical  observers 
have  supported  my  conclusion  that  there  is  a  phthisical  insanity,  Dr. 
Maudsley  going  the  length  of  saying  that  he  has  seen  many  cases 
exhibiting  a  phthisical-mindedness  not  amounting  to  technical  insanity, 
less  in  degree  but  the  same  in  kind. 

No  doubt  my  clinical  experience  of  twenty  years,  since  1863,  has 
modified  to  some  extent  some  of  my  conclusions  of  that  date.  For 
instance,  I  do  not  now  look  on  phthisical  insanity  as  being  so  incurable  a 
condition  as  I  did  then ;  but  I  had  not  then  had  the  experience  of  the 
working  of  modern  hygienic  ideas  in  asylums,  or  of  the  most  recent 
modes  of  treating  the  insane  therapeutically  and  morally.  But,  on  the 
other  hand,  my  experience  has  strengthened  the  conviction  that  a 
phthisical  insanity  exists,  and  in  the  typical  cases  is  well  marked  in  its 
characters,  and  that  it  is  difierent  in  many  essential  points  from  any 
of  the  other  forms  of  anaemic  or  diathetic  insanities.  It  does  not  arise 
in  asylums  through  any  defects  in  their  hygienic  conditions  or  otherwise. 
The  patients  labor  under  it  when  they  come  into  asylums.  Its  existence 
and  amount  have  no  fixed  relationship  to  the  death-rate  from  phthisis  in 
the  institution  at  all,  for  I  find  that  while  in  the  nineteen  years  1842- 
1861,  the  death-rate  from  this  disease  in  the  Royal  Edinburgh  Asylum 
was  twenty-nine  per  cent.,  I  estimated  in  1863  from  the  symptoms 
of  patients  put  down  in  the  case-books  that  for  the  ten  previous  years 
about  three  per  cent,  of  the  admissions  were  cases  of  phthisical  insanity  ; 
and  in  the  ten  years  1873—1882,  when  the  mortality  from  phthisis  has 
only  been  fifteen  per  cent.,  I  have,  from  my  own  personal  knowledge  of 
each  case,  diagnosed  and  recorded  at  the  time  two  per  cent,  of  those 
admitted  as  suffering  from  phthisical  insanity.  Those  two  things,  there- 
fore, so  liable  to  be  confounded  with  each  other,  the  general  death-rate 
from  phthisis  and  the  number  of  cases  of  phthisical  insanity  admitted  into 
an  institution,  must  be  put  entirely  apart. 

The  general  characters  of  phthisical  insanity  are  such  as  might  be 
expected  to  be  found  in  persons  of  weak  vitality.  There  is  no  acuteness 
of  vigor  about  the  symptoms  of  the  disease.  Looked  at  solely  from  the 
point  of  view  of  the  mental  symptoms  present,  some  of  the  cases  w'ould 
be  called  mania  of  the  mildly  delusional,  slightly  demented  type;  more 
of  them  would  be  called  melancholia,  also  of  the  mildly  delusional  type; 
and  many  of  them  would  be  called  monomania  of  suspicion.  It  is  a  very 
striking  fact  in  regard  to  the  last,  that  nearly  all  pure  cases  of  monomania 
of  suspicion  sooner  or  later  die  of  phthisis.  The  symptom  of  a  morbid 
mental  suspicion  runs  through  all  the  cases  of  phthisical  insanity.  Some- 
times, but  not  commonly,  they  have  an  acute  stage  at  first,  but  this  is 
always  short.  Most  frequently  the  disease  begins  by  a  gradual  alteration 
of  disposition,  conduct,  and  feeling  in  the  direction  of  morbid  suspicion 
of  those  about  the  patient,  a  morbid  fickleness  of  purpose,  an  unsocia- 
bility, an  irritability,  and  an  entire  want  of  buoyancy  and  proper  enjoy- 
ment of  life.  Along  with  this  there  are  loss  of  weight,  indigestion, 
intolerance  of  fat,  want  of  enjoyment  of  food,  perversion  of  taste  in 


PHTHISICAL    INSANITY.  329 

regard  to  food,  and  a  bad  color  of  the  skin.  There  may  or  there  may 
not  be  any  chest  symptoms  present;  most  frequently  there  are  not. 
Then  comes  the  acutest  part  of  the  attack,  if  there  is  such  a  stage  in  the 
case.  The  patient  gets  sleepless  and  mildly  melancholic  or  maniacal,  the 
bodily  state  running  down  all  the  time.  The  organic  enfeeblement  that 
characterizes  the  disease  is  often  shown  by  refusal  of  food.  The  patient 
thinks  he  is  being  poisoned,  this  no  doubt  being  the  convolutional  mis- 
interpretation of  the  pain  and  uneasiness  of  indigestion.  In  a  way,  he 
is  often  poisoned,  for  his  food  is  badly  digested  and  assimilated,  and  the 
subjective  sensations  accompanying  this  are  not  unlike  some  kinds  of 
poisoning.  After  a  little,  the  patient  becomes  irritable,  sullen,  unsociable, 
and  suspicious,  his  state  varying  from  time  to  time.  The  intellectual 
processes  are  not  so  much  enfeebled  as  there  is  a  disinclination  to  exercise 
them.  There  are  occasional  unaccountable  little  attacks  of  excitement. 
The  patient  is  disinclined  to  amuse  or  employ  himself.  He  looks  on  any 
attempt  to  persuade  him  to  do  so  as  persecution,  and  as  being  prompted 
by  hostile  motives.  There  is  some  depression,  but  no  intense  mental 
pain.  The  patient  associates  with  no  one,  and  the  kindnesses  of  relatives 
merely  call  forth  reproaches.  If  the  patient  lives  long,  he  becomes  more 
silent  and  apparently  demented,  but  he  can  always  be  roused  out  of  this 
for  a  short  time.  Complete  typical  dementia  does  not  usually  occur.  If 
there  is  any  tendency  to  periodicity,  the  remissions  and  aggravations  are 
not  regular  or  complete.  Bodily  he  cannot  be  fattened,  he  looks  sallow 
and  haggard,  his  circulation  is  poor,  his  pulse  weak,  and  anything  like 
tone  is  entirely  absent.  There  is  no  muscular  energy,  and  a  strong  dis- 
inclination to  exertion.  The  appetite  is  poor  and  capricious.  Colds  are 
taken  vei-y  easily.  The  patients  lose  weight  and  are  all  round  worse  in 
cold  weather.  The  temperature  tends  to  be  low  until  the  lungs  become 
affected,  and  then  there  is  an  insidious  evening  rise,  which  is  perhaps  the 
only  sign  of  the  presence  of  a  bodily  disease.  In  very  many  of  the  cases 
— one-half  the  number,  according  to  my  experience — the  chest  symptoms 
are  at  first  latent  even  after  the  lungs  have  become  markedly  affected. 
There  is  no  cough  or  spit  or  pain.  I  have  often  happened  to  notice  that 
a  patient  laboring  under  phthisical  insanity  (and  this  applies  to  cases  of 
dementia  and  many  cases  of  acute  insanity,  too)  was  breathing  a  little 
more  quickly  than  normal,  or  was  looking  more  pinched,  or  was  falling 
off  his  food,  or  his  pulse  was  quicker  and  weaker  than  usual,  or  he  had  a 
hectic-looking  spot  on  one  cheek,  or  his  skin  felt  hot;  and  on  examining 
the  chest  in  consequence  of  some  such  indication,  I  have  found  extensive 
broncho-pneumonia,  or  consolidation,  or  breaking  up  of  the  lung  tissues. 
The  progress  of  the  lung  disease  varies  much  in  different  cases,  in  some 
being  rapid  and  causing  death  in  a  few  months,  and  others  going  on  for 
years  if  the  conditions,  food,  and  hygiene  are  favorable.  I  have  seen 
such  cases  in  the  very  feverish  stage  before  death,  when  the  temperature 
rose  over  102°,  rouse  up  wonderfully,  and  even  cease  to  manifest  the 
morbid  suspicions,  but  such  cases  are  exceptional.  It  would  seem  as  if 
in  these  cases  the  high  temperature  and  quickened  circulation  stimulated 
the  anaemic  and  ill-nourished  convolutions  to  increased  and  almost  normal 
mental  activity. 


330  PHTHISICAL    INSANITY. 

The  following  is  an  example  of  the  disease : 

J,  N.,  set.  43.  Her  previous  history  was  not  known  very  accurately, 
but  this  seems  to  have  been  the  first  attack  of  insanity  ;  it  had  not  existed 
more  than  a  few  months.  She  resided  in  London,  and  came  to  Edinburgh 
to  seek  her  son,  who  had  been  dead  some  time.  This  she  had  known 
before  she  became  insane.  No  hereditary  predisposition  was  known. 
She  had  been  wandering  about,  and  was  troublesome,  but  not  violent. 

On  admission  she  was  apathetic,  and,  when  roused,  suspicious-looking, 
not  answering  questions  correctly  or  even  intelligently,  but  showing  her 
insanity  much  more  by  her  peculiar  expression  of  face  and  her  conduct 
when  spoken  to  than  by  her  conversation.  Hair  dark,  complexion  dark. 
She  is  of  the  melancholic  temperament.  She  was  on  admission  thin  and 
weak,  but  appeared  before  becoming  insane  to  have  enjoyed  good  bodily 
health  on  the  whole. 

After  being  some  months  in  the  asylum,  her  mental  state  was  as  follows : 

"  She  has  many  delusions,  which  she  only  shows  at  times,  and  is  not 
very  consistent  in  her  expression  of  them.  She  fancies  that  she  is  preg- 
nant, that  the  foetus  is  extrauterine,  and  that  she  will  require  to  be 
operated  upon.  She  is  very  suspicious,  especially  of  her  food,  sometimes 
starving  herself  through  fear  of  being  poisoned.  She  also  at  times  seems 
to  imagine  that  she  has  much  property  that  is  being  kept  away  from  her. 
She  is  very  idle,  and  cannot  by  any  means  be  persuaded  to  employ  her- 
self. At  times,  without  any  cause,  she  becomes  abusive  to  those  about 
her,  and  much  excited.  She  remains  thin  and  pale,  but  takes  her  food 
well,  but  has  shown  no  clear  symptoms  of  suffering  from  any  actual  lung 
disease.  She  is  unsociable,  takes  no  interest  in  her  friends,  does  not 
want  to  get  away  from  the  asylum,  or  at  least  expresses  no  wish  to  do  so. 
She  gets  excited  for  short  periods  of  a  few  hours  at  times,  and  during 
these  attacks  of  excitement  all  her  symptoms  are  much  worse." 

And  in  the  course  of  two  years  her  state  was  the  following: 

She  is  now  much  thinner  and  weaker  than  she  was,  but  no  symptoms 
of  any  disease  have  manifested  themselves,  and  she  refuses  to  allow  any 
examination  to  be  made  of  her  chest.  She  is  more  taciturn  and  less 
seldom  abusive,  except  when  she  is  spoken  to  or  interfered  with.  She 
never  speaks  to  anyone,  except  to  ask  for  something  she  wants,  resents 
being  interfered  with  in  any  way,  and  treats  all  about  her  as  if  they  were 
her  enemies.  When  asked  about  her  health  she  frequently  becomes 
abusive,  and  seems  to  think  some  insult  or  harm  is  meant  her.  She  is 
never  pleasant  by  any  possibility,  and  never  thankful  for  any  attention 
shown  her.  She  distinguishes  in  no  way  those  who  are  kind  to  her  from 
those  with  whom  she  has  nothing  to  do.  At  long  intervals  now  she 
becomes  excited,  abusive  to  some  one  who  has  given  no  cause  for  such 
conduct,  and  she  assigns  no  reason  for  such  abuse. 

She  remained  mentally  as  described,  but  in  bodily  health  became 
weaker,  lost  flesh,  and  did  not  take  her  food  so  well,  but  no  cough  or 
spit  appeared  till  two  months  before  her  death,  which  occurred  after  she 
had  been  in  the  asylum  five  years.  For  two  or  three  years  before  death 
she  had  been  thin,  pale,  weak,  capricious  in  her  appetite,  inclined  to  keep 
her  bed,  and  evidently  laboring  under  organic  disease.  She  resisted  an 
examination  of  her  chest  so  very  strongly  that  it  was  never  thoroughly 


PHTHISICAL    INSANITY.  331 

made.  There  was  never  any  diarrhoea,  but  all  the  other  symptoms  of 
phthisis  were  present  in  great  severity  for  two  months  before  death. 

Post-mortem  Examination. — The  brain  was  atrophied,  anaemic,  and 
cedematous.  The  white  substance  composing  and  surrounding  the  fornix 
and  septum  lucidum  was  almost  diffluent.  The  left  lung  was  everywhere 
infiltrated  with  masses  of  tubercle,  each  tubercular  spot  soft  in  the  centre. 
The  cavities  so  formed  were  many  of  them  evidently  very  old.  The 
upper  lobe  of  the  right  lung  was  in  a  similar  condition.  The  mesenteric 
glands  were  enlarged  and  tubercular.  The  mucous  membrane  of  the 
caecum  and  ascending  colon  was  ulcerated,  thickened,  and  red. 

Commentary  on  such  a  case  is  almost  superfluous  after  what  I  have 
said  about  phthisical  insanity.  A  woman  has  a  family,  and  lives  till  she 
is  forty-three.  She  then  becomes  insane,  never  having  very  acute  symp- 
toms, suspicion,  irritahility,  unsociahility,  with  causeless,  unaccountable 
exacerbations,  and  a  ivant  of  interest  in  anything,  being  the  chief  symp- 
toms. She  is  thin  and  in  weak  bodily  health  when  she  becomes  insane, 
and  although  having  good  food  and  fresh  air  never  gets  stronger.  She 
becomes  weaker,  paler,  and  thinner  gradually,  until  she  is  exhausted  and 
very  weak,  and  then  a  severe  cough  and  spit  comes  on  two  months  before 
she  dies.  Can  anyone  doubt  that  in  this  case  the  insanity  was  contem- 
poraneous in  its  appearance  with  the  preliminary  symptoms  of  tubercu- 
losis, that  the  ordinary  symptoms  of  the  latter  disease  were  obscured  by 
the  state  of  the  brain,  and  that  it  was  the  tuberculosis,  and  not  the 
insanity,  that  kept  the  patient  thin  and  weak  bodily  ?  And  do  not  the 
mental  symptoms  resemble  in  some  degree  those  of  an  exhausted  man 
whose  brain  has  been  starved  of  a  sufficient  supply  of  nourishment  by  a 
disabled  stomach,  an  exhaustive  discharge,  or  unsound  lungs? 

J.  0.,  aet.  31,  a  joiner.  Father  had  been  insane.  Had  led  a  dissi- 
pated life  at  times.  Had  always  made  his  living  at  his  trade.  Was 
married,  and  had  a  family.  The  first  symptoms  of  insanity  were  noticed 
more  than  a  year  ago,  and  he  was  then  sent  to  an  asylum,  but  having 
apparently  quite  recovered,  he  was  discharged.  He  was  never  quite  well 
after  this,  however.  He  was  unsettled,  would  not  work  at  his  trade  with 
any  one  master  for  more  than  a  few  weeks  at  a  time.  He  accused  his 
wife  of  poisoning  him,  of  conspiring  against  him,  and  of  getting  her 
relations  also  to  plot  against  his  life.  His  having  been  in  an  asylum  at 
all  he  attributed  entirely  to  their  desire  to  get  rid  of  him  for  their  own 
purposes. 

On  admission  into  the  asylum  he  was  generally  quiet,  reserved,  and 
suspicious  in  look  and  manner,  without  showing  much  suspicion  in  his 
words.  He  was  a  man  in  average  health,  with  a  fair  complexion,  dark- 
brown  hair,  and  a  more  than  usually  intelligent  face.  He  was  very 
reticent  about  his  delusions. 

For  some  time  after  admission  he  wrought  in  the  joiner's  shop,  but 
then  began  to  fancy  that  his  Avorking  there  kept  him  in  the  asylum,  and 
refused  to  work  any  longer.  He  became  more  unreserved  in  his  expres- 
sions of  dislike  and  suspicion  of  his  wife  and  her  relations.  He  might 
often  be  seen  to  exchange  his  own  dish  for  that  of  his  next  neighbor  at 
meals,  when  he  could  do  so  without  attracting  much  attention.  He 
looked  as  if  he  "knew  all  about  it"  when  asked  about  this  proceeding, 


332  PHTHISICAL    INSANITY. 

but  would  give  no  explanation  of  it.  He  evidently  had  strong  prejudices 
against  the  head  male  attendant,  and  shook  his  head  and  laughed,  and 
said,  "You  know  very  well,"  when  asked  why  he  disliked  this  man.  At 
one  time  he  became  so  well  that  his  discharge  from  the  asylum  was  con- 
templated. 

He  had  not  been  in  the  asylum  six  months  till  he  had  slight  haemop- 
tysis, and  when  his  chest  was  examined  the  presence  of  tubercular  disease 
was  indicated  by  dulness  on  percussion,  and  crepitation  on  auscultation 
at  the  apices  of  both  lungs.  He  said,  however,  that  he  had  often,  before 
he  came  into  the  asylum,  spat  blood.  Shortly  afterwards,  his  condition 
was  the  following: 

"  He  now  works  in  the  joiner's  shop  only  when  he  is  almost  obliged 
to  do  so.  He  often  requires  to  be  told  that  he  will  be  carried  out  if  he 
will  not  walk.  He  does  not  need  to  work  hard,  and  is  only  asked  to 
"work  at  all  for  his  own  sake,  because  when  he  is  employed  in  any  way 
he  is  much  happier  and  more  content  than  when  quite  idle.  He  some- 
times abuses  the  head  attendant  in  most  unmeasured  language.  He 
imagines  he  is  the  heir  to  large  estates,  and  is  kept  here  a  prisoner  by 
his  wife's  relations  to  exclude  him  from  his  inheritance.  No  amount  of 
persuasion  will  convince  him  that  this  is  not  the  case.  He  is  suspicious 
of  almost  everyone  round  him ;  he  tries  to  exchange  the  portion  put 
before  him  at  every  meal  for  that  of  some  one  else.  He  is  at  times  very 
irritable,  and  gets  much  excited.  He  took  cod-liver  oil  for  some  days, 
but  then  imagined  it  was  poisoned,  and  refused  to  take  it  on  any  account. 
He  is  constantly  asking  for  changes  of  diet,  and  when  he  gets  them  he 
remains  as  dissatisfied  as  before.  He  is  still  pretty  strong,  and  is  in  good 
condition;  but  complains,  when  at  work,  of  shortness  of  breath.  It  is 
not  for  this  that  he  refuses  to  work,  however ;  he  imagines  that  it  will  be 
the  means  of  keeping  him  longer  here.  His  most  common  question  to 
the  reporter  every  day  is,  "When  will  this  have  an  end?"  referring  to 
the  conspiracy  which  he  imagines  is  being  formed  against  him.  At  times 
he  is  entirely  reticent,  merely  shaking  his  head  significantly  when  asked 
how  he  is — "  Oh,  you  know  well  enough,  why  ask  me  ?" 

A  year  after  admission  he  w^as  attacked  with  a  cough  and  spit,  and  his 
difiiculty  of  breathing  became  increased,  and  he  was  no  longer  asked  to 
do  any  work.  He  got  much  worse  mentally  immediately  after  he  was 
allowed  to  be  quite  idle.  He  could  never  be  induced  to  take  any  kind 
of  medicine  for  more  than  a  day  or  two,  and  the  extra  diet  and  stimu- 
lants ordered  for  him  were  almost  forced  down  his  throat.  The  lung 
disease  advanced  rapidly.  He  became  worse  every  week,  while  his  sus- 
picions and  irritability  became  the  cause  of  more  and  more  misery  to 
him.  He  gasped  reproaches  against  the  medical  officer,  as  he  sat  cough- 
ing and  breathless,  for  giving  him  the  medicines  intended  to  relieve  him. 
Everything  that  was  done  for  him  he  imagined  to  be  for  a  sinister  purpose, 
everyone  who  was  kind  to  him  he  suspected  of  being  an  enemy,  and  all 
the  symptoms  of  his  disease  he  believed  to  be  caused  by  his  food  or 
medicine.  All  his  symptoms  were  as  severe,  when  they  once  had  fairly 
commenced,  as  in  ordinary  cases  of  phthisis  among  the  sane. 

To  the  last  he  retained  his  delusions  unchanged.     He  died  within 


PHTHISICAL    INSANITY.  .        333 

eighteen  months  from  the  time  of  his  admission.  He  was  much  ex- 
hausted, but  not  quite  emaciated,  when  he  died. 

Post-mortem  Examination. — The  brain  was  on  the  whole  almost 
normal,  except  that  the  arachnoid  was  very  milky,  and  the  pia  mater 
infiltrated  with  opaque  serum,  while  the  lining  membranes  of  the  ven- 
tricles were  thickened  and,  in  the  anterior  part  of  the  lateral  ventricles, 
covered  with  small  granulations. 

The  lungs  were  both  almost  entirely  infiltrated  with  tubercle.  This 
tubercle  was  very  hard,  however,  except  in  some  softened  spots.  It  was 
intermixed  with  the  fibrous  pneumonic  lung,  and,  as  was  seen  from  the 
appearance  of  some  of  the  vomicae,  as  well  as  the  consolidated  fibrous 
lung,  the  organ  had  been  affected  for  a  long  time.  The  cavities  and  the 
densest  parts  of  the  tubercular  deposit  in  both  lungs  were  at  the  bases. 
There  was  no  ulceration  of  the  caecum  or  colon.  The  mucous  membrane 
of  the  stomach  and  duodenum  was  of  a  very  dark  color  and  very  soft. 

This  is  a  good  example  of  those  cases  of  monomania  of  suspicion, 
almost  all  of  whom,  according  to  my  statistics,  die  of  tuberculosis.  The 
insanity  was  strongly  hereditary. 

Such  are  the  main  and  typical  features  of  phthisical  insanity,  and  the 
foregoing  are  good  examples  of  the  disease.  Certain  general  questions 
arise  in  regard  to  it  for  answer.  Are  all  cases  where  we  have  phthisis 
among  the  insane  apt  to  be  of  the  mental  type  I  have  described  ?  No, 
only  those,  in  my  opinion,  who  have  had  the  well-known  bodily  symp- 
toms of  the  pretubercular  stage  of  phthisis.  The  most  marked  cases  are 
those  with  a  hereditary  tendency  to  both  phthisis  and  insanity,  or  to  the 
neuroses.  It  is  surprising  how  often  both  diseases  occur  in  different 
members  of  the  same  family.  No  physician  in  extensive  practice  but 
has  met  with  very  many  such  families.  They  are  too  frequent  to  be  a 
mere  coincidence.  The  constitutional  weakness  which  tends  to  end  in 
phthisis  is,  I  have  no  doubt,  akin  in  some  degree,  under  some  conditions, 
to  that  which  tends  to  end  in  insanity.  If  one  function  of  the  brain  is 
to  govern  the  trophic  processes  of  the  body,  and  if  that  organ  is  strongly 
predisposed  to  go  wrong  in  its  mental  functions  in  any  case,  it  stands  to 
reason  that  the  law  of  the  solidarity  of  action  of  the  whole  organ  will 
come  in,  and  that  the  nutritive  processes  will  often  be  afiected  also,  and 
the  recuperative  and  resistive  power  lessened.  Daily  experience  among 
the  insane  shows  us  that  this  is  so.  As  I  said  when  speaking  of  the 
nature  and  treatment  of  melancholia,  thinness  is  its  bodily  essence  and 
almost  constant  accompaniment,  and  fatness  its  natural  cure.  So  in 
regard  to  that  special  tendency  to  depraved  or  weakened  trophic  energy 
that  speedily  tends  to  end  in  lung  disease,  if  it  is  not  cured  it  tends  to 
afiect  the  nutrition  of  the  brain,  and  the  result  is  phthisical  insanity. 
Ascertainable  hereditary  predisposition  to  insanity  exists  in  seven  per 
cent,  more  of  the  cases  of  phthisical  insanity  than  in  the  insane  generally. 

Which  disease  begins  first  as  an  actuality  ?  The  insanity  in  most 
cases,  undoubtedly.  In  most  instances  it  exists  several  years  before  any 
discoverable  lung  trouble  appears,  just  as  there  are  many  persons  who 
have  all  the  premonitory  symptoms  of  phthisis  long  before  the  lungs  are 
affected.  I  am  not  now  entering  into  the  question  of  the  different  forms 
of  phthisis,  or  the  modes  in  which  the  lungs  are  affected,  or  into  the 


334  PHTHISICAL    INSANITY. 

specific  germ  theory  of  tubercle.  By  the  phthisis  I  speak  of,  I  mean 
that  typical  form  where  there  has  been  a  marked  constitutional  tendency 
to  malnutrition  and  lung  disease,  that  form,  in  short,  which  is  usually 
hereditary,  and  always  has  far  more  symptoms  than  the  mere  lung 
disease  to  characterize  it.  The  mode  and  time  at  which  the  lungs  are 
affected  by  actual  disease  are  accidents  due  to  special  circumstances,  such 
as  exposure  to  cold. 

In  regard  to  the  question  whether  insanity  is  not  sometimes  cured  by 
the  advent  of  lung  disease,  I  confess  I  have  never  seen  any  real  instance 
of  it.  I  have  seen  many  cases  where  patients  brightened  up,  and  were 
less  melancholic  and  far  less  torpid  after  the  temperature  rose  through 
aggravation  of  lung  disease,  and  I  have  seen  this  occur  repeatedly  in  the 
same  case  as  the  inflammatory  process  became  active.  But  the  improve- 
ment Avas  only  apparent,  and  was  always  transitory.  It  simply  resulted 
from  the  increased  temperature  and  more  active  circulation  in  the  brain. 
Any  disease  that  produces  those  conditions  will  have  the  same  effect. 

A  very  interesting  question  arises  as  to  the  effect  of  phthisis  on  the 
mental  condition  of  sane  persons.  There  is  the  universally  recognized 
sjJes  phthisica,  and  there  is  often  also  a  mental  brilliancy,  short  and 
fitful  like  the  light  of  an  ill-supplied  lamp,  and  there  are  delirious,  leth- 
argic, and  confused  times,  in  different  cases.  In  very  many  there  is  a 
fancifulness,  a  causeless  changing  from  hope  to  despondency,  an  inca- 
pacity for  continuous  thought,  that  seems  to  characterize  this  disease 
more  than  other  chronic  ailments.  Doctors  do  not  see  these  things 
so  much,  for  at  their  visit  the  patients  pick  themselves  up  mentally ;  but 
ask  nurses  and  relatives  who  are  with  such  persons  all  the  time,  and  they 
will  tell  you  of  many  small  mental  peculiarities  of  sane  phthisical  patients. 

In  order  to  exhibit  the  results  of  my  experience  in  regard  to  phthisical 
insanity  for  nine  years  1874—1882  inclusive,  in  a  statistical  form,  I  have 
gone  carefully  through  the  case-books  of  the  Royal  Edinburgh  Asylum. 
Each  case  was  diagnosed  as  to  its  clinical  mental  type  Avithin  the  year  of 
its  admission.  This  is  perhaps  too  soon  in  this  form  of  insanity,  for,  as  I 
mentioned,  some  of  the  patients  have  a  regular  maniacal  and  melancholic 
attack  to  begin  with,  of  short  duration,  before  they  settle  down.  The 
general  result  was  this  :  During  those  nine  years  there  have  been  thirty- 
one  hundred  and  forty-five  admissions.  Of  these,  eighty-five  have  been 
diagnosed  as  phthisical  insanity.  This  is  3,7  per  cent,  .of  the  cases 
admitted.  Following  out  these  eighty-five  cases,  I  find,  that  twenty-six 
have  been  discharged  recovered.  This  is  a  recovery  rate  of  thirty  per 
cent.  The  recovery  rate  in  the  asylum  during  the  same  period  has  been 
forty-six  per  cent.  This  would  show,  supposing  my  diagnosis  to  have 
been  correct,  that  cases  of  phthisical  insanity  recover,  but  in  much  less 
proportion  than  the  average  of  patients  sent  to  the  asylum,  which  include, 
it  must  be  remembered,  many  general  paralytics,  paralytics,  dements,  and 
other  cases,  hopeless  from  the  beginning.  The  recovery  rate  among  the 
patients  admitted  with  no  recognizable  organic  brain  disease,  and  who 
had  been  less  than  a  year  insane  before  admission,  was  at  least  seventy 
per  cent.  We  may  say,  therefore,  that  the  cases  diagnosed  as  phthisical 
insanity  recover  in  much  less  than  half  the  proportion  that  cases  of 
insanity  uncomplicated  with  brain  disease  do.    In  order  that  this  propor- 


rUTHlSlCAL    INSAXITY.  335 

tion  of  phthisical  insanity  should  recover,  special  treatment — dietetic, 
moral,  and  medicinal — is  required  to  combat  the  depraved  general  and 
brain  nutrition  present. 

I  next  inquired  into  the  death-rate  from  tubercular  complaints  among 
the  eighty-five  phthisically  insane  patients.  Up  to  this  time  eighteen 
have  died  of  phthisis,  but  it  must  be  taken  into  account  that  in  addition 
to  the  twenty-six  who  recovered  there  were  thirty-two  cases  removed  from 
the  institution  not  recovered  mentally,  some  of  these  being  taken  home  to 
be  nursed  by  their  relations  during  their  last  illness — to  die,  in  short. 
But  more  than  the  eighteen  will  die  of  phthisis,  for  those  admitted  in  the 
recent  years  have  not  yet  had  time  to  develop  the  complaint,  and  some  of 
them  are  now  phthisical.  The  general  result  is  that  eighteen  out  of  the 
twenty-seven  who  were  not  recovered  or  removed  have  already  died 
of  phthisis. 

I  next  examined  into  the  general  statistics  of  phthisis  in  the  institution, 
quite  apart  from  phthisical  insanity,  for  the  same  period  of  nine  years. 
Eighty-three  cases  died  of  this  disease  in  that  time.  There  having  been 
altogether  six  hundred  and  thirteen  deaths  in  the  time,  this  was  at  the 
rate  of  13.5  per  cent.,  or  one  in  seven.  Of  all  the  deaths  from  phthisis, 
therefore,  21.7  per  cent.,  or  just  over  one  in  five,  had  been  originally 
diagnosed  as  phthisical  insanity.  Looking  at  the  other  clinical  forms  of 
insanity  who  died  of  phthisis,  none  of  them  approach  in  number  the 
phthisical  insanity.  Seven  cases  of  epileptic  insanity  died  of  phthisis 
and  seven  cases  of  general  paralysis  (though  the  large  number  of  this 
disease  who  died  of  phthisis,  I  think,  is  much  more  than  the  average), 
and  five  cases  of  adolescent  insanity,  but  beyond  these  no  special  variety 
was  found  in  the  phthisical  list. 

In  going  over  those  patients  who  had  died  of  phthisis  I  had  an  oppor- 
tunity of  seeing  a  clinical  fact  in  regard  to  the  efiect  of  the  development 
of  phthisis  in  one  or  two  cases  on  a  previously  existing  insanity.  In 
such  patients  it  often  had  the  eifect  of  producing  a  mental  condition 
similar  to  the  symptoms  of  phthisical  insanity  in  patients  who  had  not 
labored  under  such  mental  symptoms  before.  Such  patients  became 
suspicious,  sullen,  irritable,  and  unsocial,  some  of  them  being  also  melan- 
cholic. One  young  man,  J.  P.,  who  had  been  a  cheerful,  active  fellow, 
sociable,  and  constantly  playing  the  piano  and  singing,  became  moody, 
suspicious,  impulsive,  and  irritable  just  before  his  chest  was  found  to  be 
affected,  and  while  he  Avas  getting  thin,  not  taking  his  food,  and  looking  ill. 


LECTURE    XIV. 

UTERINE  OR  AMENORRH(EAL,  OVARIAN,  AND  HYSTERICAL  IN- 
SANITIES—THE INSANITY  OF  MASTURBATION— UTERINE  OR 
AMENORRHCEAL  INSANITY. 

No  doubt  the  influence  of  woman's  great  function  of  menstruation  is 
considerable  on  her  normal  mentalization.  It  has  a  psychology  of  its 
own,  of  which  the  main  features  generally  are  a  slight  irritability  or 
tendency  towards  lack  of  mental  inhibition  just  before  the  process  com- 
mences each  month,  a  slight  diminution  of  energy  or  tendency  to  mental 
paralysis  and  depression  during  the  first  day  or  two  of  its  continuance, 
and  a  very  considerable  excess  of  energizing  power  and  excitation  of 
feeling  during  the  first  week  or  ten  days  after  it  has  entirely  ceased,  the 
last  phase  being  coincident  with  woman's  period  of  highest  conceptive 
power  and  keenest  generative  nisus.  As  is  well  known  to  all  physicians, 
many  purely  nervous  derangements  and  diseases,  such  as  neuralgia, 
migraine,  epilepsy,  and  chorea,  are  apt  to  be  aggravated  at  the  menstrual 
periods  or  to  begin  then.  There  are  often  perversions  of  the  great  in- 
stincts and  appetites  then.  In  some  women  the  social  instincts  are  then 
partly  suspended,  and  in  others  there  are  perversions  of  the  appetites  for 
food  and  drink.  Dr.  Halliday  Croom  has  kindly  given  me  the  notes  of 
two  such  cases.  One  young  lady  patient  of  his  at  every  menstrual 
period  pulls  out  and  eats  the  bristles  of  the  hair-brushes  in  her  own 
room,  and  sometimes  goes  into  other  rooms  for  more  brushes  for  the 
same  purpose.  He  has  another  lady  patient,  married,  set.  36,  who,  for 
fifteen  years,  has  eaten  at  each  menstrual  period  salt,  dry  oatmeal,  and 
bits  of  sponge,  and  has  been  none  the  worse  for  this.  I  have  met  with 
(and  what  physician  has  not?)  cases  of  women  who  had  intense  cravings 
for  stimulants  and  narcotics  at  each  menstrual  period,  and  indulged  those 
cravings,  to  their  intense  disgust  and  regret  sometimes  afterwards.  Dr. 
Croom  gives  me  the  notes  of  a  case  where  the  craving  was  for  malt  liquors 
only. 

The  regular  and  normal  performance  of  the  usual  functions  of  the 
uterus  and  ovaries  is  of  the  highest  importance  to  the  mental  soundness 
of  the  female.  Disturbed  menstruation  is  a  constant  danger  to  the 
mental  stability  of  some  women;  nay,  the  occurrence  of  absolutely 
normal  menstruation  is  attended  with  great  risk  in  many  unstable  brains. 
The  actual  outbreak  of  mental  disease,  or  of  its  worst  paroxysms,  is  co- 
incident with  the  menstrual  period  in  a  very  large  number  of  women 
indeed.  It  does  not  follow  from  this,  of  course,  that  the  menstruation 
caused  the  insanity  in  all  such  cases.  The  constant  difficulty  the  physi- 
cian has  is  to  know  whether  the  disordered  or  suspended  menstruation  is 
a  cause  or  a  symptom.     Nearly  all  the  acute  varieties  of  insanity  disturb 


UTEEINE    OR    AMENORRH(E Ah    INSANITY.  337 

or  suspend  menstruation  in  women  while  the  acute  symptoms  last.  I 
find  that  attendants  on  the  insane  do  not  expect  menstruation  to  be 
regular,  if  present  at  all,  in  cases  of  acute  mania  or  of  intensely  excited 
melancholia.  I  also  find  that  among  the  women  patients  in  an  asylum, 
taking  them  throughout,  chronic  and  acute,  the  occurrence  of  menstrua- 
tion is  apt  to  cause  an  aggravation  of  the  morbid  mental  symptoms 
present.  The  melancholies  are  more  depressed,  the  maniacal  more  rest- 
less, the  delusional  more  under  the  influence  of  their  delusions  in  their 
conduct ;  those  subject  to  hallucinations  have  them  more  intensely,  the 
impulsive  cases  are  more  uncontrollable,  the  cases  of  stupor  more  stupid, 
and  the  demented  either  more  enfeebled  or  tending  to  be  excited.  In 
the  chronic  insane,  whose  home  the  asylum  is,  and  its  regulations  and 
routine  their  rules  of  life,  we  frequently  find  the  menstrual  periods  a 
time  when  their  subjection  to  the  asylum  discipline  is  not  so  absolute  as 
usual,  and  their  conformity  to  the  ways  of  its  daily  life  is  not  so  un- 
varying. Of  course,  there  are  a  great  many  exceptions  to  this  in  the 
chronic  insanity  of  women,  to  whom  the  menstrual  period  makes  no 
diff'erence  whatever.  Those  are  usually  patients  affected  with  quiet,  mild 
dementia,  who  work  hard  and  are  in  good  bodily  health.  At  times  we 
see  special  directions  taken  by  those  menstrual  aggravations  of  mental 
disease,  such  as  an  accentuation  of  the  emotional  perversions  that  exist, 
an  excitation  of  the  amatory  feelings  towards  the  opposite  sex,  a  stimula- 
tion of  the  habit  of  masturbation,  or  the  occurrence  of  stupor  and  con- 
fusion in  the  whole  of  the  mental  processes.  The  last  (stupor)  is  ex- 
ceedingly apt  to  occur  in  young  women  during  adolescence  about  their 
menstrual  times.  I  have  noAV  a  patient,  J.  Q.,  of  nineteen,  usually  a 
bright,  active  girl,  who,  for  about  a  week  or  ten  days  at  her  menstrual 
periods,  becomes  confused,  stupid,  and  depressed — her  face  and  whole 
muscular  movements  showing  an  extreme  hebetude  and  slowness.  Some 
few  melancholic  patients  get  maniacal  at  the  menstrual  periods;  and  I 
have  seen  a  case  of  acute  mania  cease  to  be  excited,  and  become  depressed 
and  fearful  during  menstruation. 

Taking  the  mass  of  the  more  chronic  and  quiet  cases  of  insanity,  I 
find  that  menstruation  is  just  about  as  regular  as  to  time,  and  as  normal 
in  the  amount  of  discharge  lost,  as  among  a  similar  number  of  average 
sane  women.  A  very  considerable  number  of  female  lunatics  have  the 
delusion  that  they  are  occasionally  ravished  by  men  at  night,  and  this  is 
usually  more  intense  after  menstruation. 

But  apart  from  these  general  effects  on  all  kinds  of  existing  mental 
disease,  of  disordered  or  suspended  menstruation,  insanity  in  some  few 
cases  actually  results  de  novo  from  this  as  an  exciting  or  predisposing 
cause.  Those  cases  may  be  conveniently  termed  uterine  or  amenorrhoeal 
insanity.  Most  of  them,  two-thirds  at  least,  are  melancholic  in  character, 
the  mental  symptoms  following  the  amenorrhoea,  and  passing  away  when 
regular  menstruation  returns. 

The  following  is  a  typical  case  of  this  sort:  J.  R.,  aet.  20,  of  a  neu- 
rotic but  not  an  insane  heredity.  Comes  of  an  "excitable"  family.  Had 
gone  from  a  country  district  and  farm  work  to  domestic  service  in  a  city, 
where,  after  a  year  or  two,  she  fell  off*  in  general  health,  and  ceased  to 
menstruate.     She  at  once  became  depressed,  took  morbid  ond  depressing 

22 


338  UTERINE    OR    AMENORRHOEAL    INSANITY. 

views  of  religion,  was  forgetful,  confused,  and  sleepless,  and  lost  her  ap- 
petite. She  wept  without  cause;  was  very  obstinate,  misinterpreting 
the  object  of  our  giving  her  medicine,  making  her  work,  walk,  and  keep 
herself  tidy.  She  said  she  should  be  out  of  the  world  and  was  not  fit  to 
live,  but  never  attempted  suicide.  She  was  ordered,  and  made  to  take, 
iron  and  aloes,  with  much  fresh  air  and  fattening  diet.  She  got  worse 
at  first,  and  hallucinations  of  hearing  developed.  She  distinctly  heard 
voices  telling  her  she  was  the  worst  person  alive.  She  would  have  re- 
fused food  had  she  been  allowed  to  do  so.  In  about  two  months  she 
began  to  improve  in  body  and  mind,  especially  in  bodily  looks  and  weight. 
For  three  months  longer  she  remained  depressed,  and  then  menstruated 
after  a  series  of  hot  baths  and  mustard  to  her  feet.  She  brightened  up 
from  the  first  day  of  menstruation  as  if  a  cloud  had  been  lifted  off  her 
mind,  and  she  kept  well  ever  after. 

In  such  a  case  I  do  not  think  it  was  the  amenorrhoea  alone  which 
caused  the  melancholia.  Both  were  in  reality  the  result  of  a  running 
down  in  health  and  vitality,  but  no  doubt  the  mental  symptoms  were 
greatly  aggravated  by  the  suspended  menstrual  function.  I  do  not  think 
the  melancholia  would  have  been  cured  by  a  restoration  of  menstruation, 
had  that  been  possible,  before  the  blood  had  become  richer  and  the  nutri- 
tion improved.  In  fact,  I  have  seen  the  coming  on  of  the  menses  under 
these  circumstances  aggravate  the  mental  symptoms,  the  case  assuming 
during  menstruation  a  maniacal  form.  The  treatment  of  such  cases 
should  therefore  be  directed  at  first  towards  improving  the  general  health 
more  than  towards  restoring  menstruation  merely;  at  all  events,  until 
the  nutrition  of  the  body  is  improved.  Then  the  usual  means  for  re- 
storing the  menstrual  function  should  be  resorted  to,  and  when  they  are 
successful,  or  when,  as  most  frequently  happens,  nature  restores  the 
function,  the  mental  improvement  is  often  as  marked  and  immediate  as 
in  J.  R.'s  case.  It  will  be  observed  that  some  amount  of  improvement 
took  place  in  her  mental  state  as  the  bodily  nutrition  improved  before 
menstruation  returned. 

The  melancholic  cases,  of  which  this  of  J.  R.  is  the  type,  nearly  all 
recover,  in  my  experience.  Out  of  twenty -four  of  very  typical  form 
which  we  have  had  in  the  Royal  Asylum  in  the  past  nine  years,  eighteen 
have  recovered. 

About  one-third  of  the  amenorrhoeal  cases  were  maniacal,  with  no 
melancholic  tendency.  Such  cases  were  by  no  means  so  clearly  con- 
nected with  the  absent  menstruation  as  even  the  melancholic  ones,  nor 
did  they  show  the  same  tendency  to  recover  in  mind  coincidently  with 
its  restoration.  In  fact,  I  was  by  no  means  so  sure  of  the  same  kind  of 
direct  connection  between  the  amenorrhoea  and  the  mental  symptoms  in 
most  of  them  as  in  the  melancholic  cases. 

It  is  commonly  supposed  that  the  sudden  suppression  of  menstruation 
in  a  young,  full-blooded,  healthy  woman  of  nervous  heredity,  through  chill 
or  shock,  is  very  liable  to  cause  an  outburst  of  acute  delirious  mania. 
Some  authors  speak  of  this  as  if  it  were  one  of  the  common  causes  of 
insanity.  No  doubt  it  occurs,  but  I  have  not  met  with  more  than  two 
cases  in  all  my  experience.  One  was  that  of  J.  S.,  a  girl  of  eighteen, 
stout,  florid,  and  healthy,  who  got  wet  through  and  chilled  while  men- 


OVARIAN    INSANITY.  339 

struating.  The  flow  suddenly  stopped,  and  at  once  a  fearful  headache 
came  on,  with  maniacal  delirium,  a  temperature  of  103°,  sleeplessness, 
and  very  great  violence.  A  hot  bath,  with  cold  to  the  head,  and  with 
enormous  doses  of  bromide  of  potassium,  borax,  and  ammoniated  tincture 
of  valerian,  frequently  repeated,  had  the  effect  of  diminishing  the  de- 
lirium and  reducing  the  temperature.  A  condition  of  semi-stupor  and 
confusion,  inactivity  and  listlessness  succeeded,  and  lasted  for  two  months, 
when  the  usual  mental  health  was  regained,  but  it  was  several  months 
before  menstruation  was  restored.  I  should  say  that  stupor  is  a  more 
common  mental  result  of  suppressed  menstruation  in  young  women  with 
a  nervous  heredity  than  acute  mania. 

OVARIAN   INSANITY — "OLD   MAID'S   INSANITY." 

There  is  a  somewhat  ludicrous  form  of  insanity  that  Dr.  Skae  called 
"  Ovarian,"  or  more  familiarly  and  more  correctly,  I  think,  "Old  Maid's 
Insanity."  There  is  really  no  definite  proof  that  the  ovaries  are  either 
disturbed  in  function  or  diseased  in  structure  in  those  cases,  but  it  con- 
sists no  doubt  of  a  morbid  transformation  of  the  normal  affectiveness  of 
woman  towards  the  opposite  sex.  The  disease  usually  occurs  in  unpre- 
possessing old  maids,  often  of  a  religious  life,  who  have  been  severely 
virtuous  in  thought,  word,  and  deed,  and  on  whom  nature,  just  before 
the  climacteric,  takes  revenge  for  too  severe  a  repression  of  all  the  mani- 
festations of  sex,  by  arousing  a  grotesque  and  baseless  passion  for  some 
casual  acquaintance  of  the  other  sex  whom  the  victim  believes  to  be 
deeply  in  love  with  her,  dying  to  marry  her,  or  aflame  with  sexual  passion 
towards  her,  or  who  has  actually  ravished  her  after  having  given  her 
chloroform.  Usually  her  clergyman  is  the  subject  of  this  false  belief. 
Out  of  ten  such  cases  which  I  can  recall,  seven  have  had  clergymen  as 
their  supposed  wooers  or  seducers.  In  no  case  was  there  the  very 
slightest  possible  ground  for  the  notion.  In  two  cases  the  ladies  had 
never  even  spoken  to  their  supposed  lovers.  Certain  gestures,  or,  as  in 
one  case,  the  contents  of  the  agony  columns  of  the  newspapers,  were 
sufficient  proof  to  them  of  their  beliefs.  The  annoyance  to  which  un- 
fortunate men  are  subjected  in  this  way  is  often  extreme.  Lately  a  lad_y, 
J.  T.,  now  a  patient  of  mine,  went  to  a  grocer's  shop  and  ordered  her 
supply  of  groceries  in  the  name  of  a  clerical  acquaintance,  saying  she  was 
his  wife,  telling  the  shopman  to  send  the  bill  to  him,  and  this  as  the  cul- 
mination of  a  series  of  weekly  letters  to  him  of  forty  pages  each.  I  have 
known  grave  accusations  made  to  ecclesiastical  authorities,  and  the  be- 
ginnings of  most  injurious  famas  started  by  such  insane  women.  Such 
patients  are  all  of  them  between  thirty-five  and  forty-three,  and  the 
reverse  of  sensuous  in  appearance.  Some  of  them  were  most  estimable 
ladies,  whom  it  was  impossible  not  to  pity,  the  whole  thing  was  so  con- 
trary to  the  tenor  of  their  lives,  and  so  like  a  trick  played  on  that  higher 
being  which  they  had  always  cultivated,  by  «  lower  and  more  animal 
nature  Avhich  they  had  sedulously  repressed  None  of  them  recovered 
from  this  sort  of  delusion,  but  in  tAvo  of  the  cases,  as  they  passed  into  the 
senile  period,  and  after  the  climacteric,  the  notion  became  so  theoretical 
that  they  almost  ceased  to  allude  to  it. 


340  HYSTERICAL    INSANITY. 


HYSTERICAL   INSANITY. 


That  form  of  mental  disease  which  is  complicated  with  some  of  the 
protean  symptoms  of  hysteria  should  really  be  called  ovarian  insanity,  if 
that  name  were  used  in  any  correct  sense,  for  there  is  but  little  doubt 
that  undue  excitation  or  disturbance  of  the  functions  of  the  ovaries  has 
more  to  do  with  hysteria  than  anything  else.  But  perhaps  it  is  more 
convenient  to  retain  the  name  of  hysterical  insanity.  Typical  hysteria, 
pure  and  simple,  always  has  a  mental  complication.  The  volition,  or  the 
feelings,  or  the  morals,  are  always  affected  along  with  the  purely  bodily 
symptoms.  But  these  mental  symptoms,  not  fonning  the  chief  features 
of  the  disease,  or  not  being  of  such  a  nature  as  to  make  the  patient  irre- 
sponsible or  unmanageable,  are  not  reckoned  as  being  of  the  nature  of 
technical  insanity,  at  least  among  the  rich.  Among  the  poor,  with  no 
one  to  look  after  them,  hysterical  young  women  are  often  enough  sent  to 
asylums.  And  I  have  seen  most  admirable  results  from  this.  The 
principles  of  asylum  life  and  treatment  are  the  very  best  principles  of 
treatment  for  hysteria  too.  To  put  the  patient  under  control,  to  give 
her  no  harmful  sympathy,  to  make  her  work  and  walk  out  regularly,  to 
improve  her  bodily  health,  are  always  very  good  for  a  hysterical  girl. 
We  have  had  three  cases  of  almost  typical  hystero-epilepsy,  with  a  sui- 
cidal tendency  in  two  of  them,  and  general  unmanageability  at  home  in 
the  third,  in  addition  to  the  purely  motor  and  other  symptoms,  sent  to 
this  asylum  within  the  past  few  years,  and  I  have  not  seen  or  heard  of 
any  home  or  hospital  treatment  so  effective  as  the  asylum  treatment 
proved  to  be  in  these  girls.^  But  such  patients  are  rare  in  asylums.  The 
usual  type  of  case  classified  as  hysterical  insanity  consists  of  mania  or 
melancholia  in  a  young  woman  with  one  or  more  of  the  following  char- 
acteristics well  marked,  viz.,  a  morbid  ostentation  of  sexual  and  uterine 
symptoms,  feigned  bodily  illness  to  attract  attention  and  secure  sym- 
pathy, marked  erotic  symptoms  cloaked  by  something  else,  a  morbid 
concentration  of  mind  on  the  performance  of  the  female  functions,  semi- 
volitional  retention  of  urine,  hysterical  convulsions,  a  morbid  wayward- 
ness, ostentatious  and  unreal  attempts  at  suicide.  The  fasting  girls,  the 
girls  with  stigmata,  those  who  see  visions  of  the  Saviour  and  the  saints 
and  receive  special  messages  in  that  way,  the  girls  who  give  birth  to  mice 
and  frogs,  and  those  who  live  on  lime  and  hair,  are  all  cases  of  this 
disease. 

Hysterical  symptoms  are  exceedingly  apt  to  occur  in  the  insanities  of 
puberty  and  adolescence,  and  along  with  those  symptoms  the  habit  of 
masturbation  is  common.  It  is  sometimes  difficult,  therefore,  to  know 
whether  to  classify  such  cases  as  adolescent,  hysterical,  or  masturbational 
insanity.  All  one  can  do  is  to  ascertain  if  the  hysterical  symptoms  are 
the  most  marked  and  prominent  features  of  the  case  before  we  call  it 
hysterical  insanity. 

The  following  case  of  hysterical  insanity  fairly  illustrates  the  general 
features  of  the  disease. 

^  Two  of  these  are  recorded  by  Mr.  T.  Inglis  in  the  Edinburgh  Medical  Journal, 
December,  1878. 


HYSTERICAL    INSANITY.  341 

J.  U.,  aet.  21,  of  a  nervous  and  excitable  temperament;  habits  correct. 
An  aunt  epileptic.  Had  on  one  occasion  at  home  a  mild  attack  of  what 
must  have  been  subacute  maniacal  excitement.  The  cause  of  the  present 
attack,  which  has  lasted  for  four  days,  was  a  fright  which  first  produced 
ordinary  hysterical  symptoms,  and  then  maniacal  symptoms  engrafted  on 
them.  She  shouted  and  screamed,  spoke  of  hearing  God  speaking  to 
her,  and  would  rush  to  the  window  to  jump  out.  She  imagined  she  was 
a  most  important  person,  attitudinized  and  did  everything  to  attract  at- 
tention to  herself.  Attention  and  sympathy  were  craved  by  her,  and  if 
she  could  not  get  them  in  one  way  she  tried  another.  She  refused  her 
food,  saying  it  was  poisoned,  but  took  it  rather  than  be  fed  with  the 
stomach-pump.  She  had  menorrhagia,  and  was  most  minute  and  cir- 
cumstantial in  the  details  as  to  her  female  health.  She  was  tried  with 
hyoscyamine,  valerian,  and  mono-bromide  of  camphor  with  apparent 
benefit;  but  I  considered  the  greatest  improvement  was  produced  in  her 
case  by  discipline,  work,  open-air  exercise,  tonics,  and  good  plain  food  in 
abundance.  She  improved  at  first,  and  once  or  twice  relapsed,  but  in 
two  months  she  recovered  and  was  discharged.  I  do  not  like  to  keep 
hysterical  cases  too  long  in  the  asylum  after  convalescence  as  a  general 
rule,  for  they  sometimes  get  too  fond  of  the  place,  preferring  the  dances,, 
amusements,  and  general  liveliness  of  asylum  life,  even  with  its  restric- 
tions, to  the  humdrum  and  hard  work  of  poor  homes. 

The  following  very  characteristic  letter  of  a  maniacal  hysterical  girl, 
J.  v.,  very  well  illustrates  the  trains  of  thought  in  such  a  case  •} 

"My  Dear  Mamma. — It  is  time  that  I  leave  to  return  home.  I  have  been 
tremendously  changed  for  the  better.  I  think  papa  will  be  able  to  get  me  a  com- 
mission under  Garibaldi  before  long.  There  are  three  to  whom  I  am  especially  in- 
debted— one  Mr  C,  the  modeller,  the  other  the  doctor,  a  Eunuch,  who  modelled  me 
at  the  fire,  and  attended  on  me  and  bathed  me.  He  is  I  am  sure  a  gentleman,  a 
splendid  doctor.  Could  not  papa  get  him  into  a  regiment  abroad  ?  And  there  is  the 
nurse.  Could  not  papa  get  him  any  situation  away  from  Morningside  Asylum  where 
I  am  at  present  ?  I  should  like  papa  to  come  for  me  as  soon  as  possible.  Do  you  re- 
member the  verse,  "  There  are,"  «&c.  (12th  verse  19th  chapter  of  Matthew).  About 
Eunuchs  ?  Then  1  beg  to  inform  you  that  according  to  Scripture  and  my  conscience, 
Jessy,  your  cook,  is  a  man  ;  and  Janet,  the  mad  devil  is  a  man  ;  and  D.  and  H.,  boys 
who  can  have  children.  Aunt  I.  is  a  man,  and  yourself  also,  both  made  of  men,  and 
I  am  a  boy,  made  of  Dr  C.  and  Dr  Z.  Mrs  T.  is  a  man,  made  of  men.  They  are 
very  ignorant  on  this  subject  here ;  but  as  for  me  it  is  certain  that  at  least  the  spirits 
have  showed  me,  which  Christ  sent  when  I  was  under  drugs  ;  they  showed  me  this. 
I  have  at  times  since  I  came  here  passed  the  shadow  of  death,  and  therefore  am 
authorised  to  speak  in  opposition  to  all  men  and  women,  gentlemen  and  ladies  who 
oppose  me.  I  am,  I  can  I  swear,  as  you  want  to  know  what  sex  I  belong  to,  a 
mixture  of  a  nymph  and  a  half-man,  half-woman,  and  a  boy,  and  a  dwarf,  and  a 
fairy.  I  know  more  than  my  fellow  mortals,  having  expired  eleven  times  before  the 
time. — I  am,  &c. " 

Our  Statistics  of  hysterical  insanity  show  a  good  proportion  of  re- 
coveries. In  the  nine  years,  1874—82,  there  were  thirty-four  female 
patients  so  classified,  and  of  those  who  were  treated  to  the  termination 
of  their  malady  sixty  per  cent,  recovered. 

1  "  Morisonian  Lectures  "  for  1873,  by  Drs  Skae  and  Clouston,  Journal  of  Mental 
Science,  vol.  xix.  p.  500. 


342  THE    INSANITY    OP    MASTURBATION. 


THE    INSANITY    OF   MASTURBATION. 

The  unnatural  gratification  of  the  sexual  appetite  through  masturbation, 
it  must  be  admitted,  is  very  common  among  boys  and  lads.  Especially, 
we  believe,  among  lads  of  the  educated  classes,  brought  together  in  the 
somewhat  artificial  if  not  unnatural  life  of  our  public  schools,  does  it 
prevail.  I  believe  that  the  more  healthy  and  more  stolid  country  lad, 
the  son  of  the  farm  laborer,  is  not  so  apt  to  indulge  in  this  unnatural 
and  disgusting  practice  as  the  son  of  the  professional  man,  supposing 
each  to  be  initiated  in  the  same  way.  Boys  are  taught  the  habit,  and 
begin  to  practise  it,  often  long  before  they  know  or  can  know  the  real 
difierence  between  sexual  good  and  evil.  But  a  healthy  constituted  lad 
in  body,  mind,  and  morals  does  not  tend  to  come  under  its  influence  to 
any  very  hurtful  extent.  His  natural  organic  repugnance  to  it  strengthens 
as  he  grows  up.  If  he  is  fortunate  enough  to  have  a  home,  or  access  to 
family  life,  his  lower  instincts  are  transformed  and  elevated  into  the  normal 
social  instincts,  through  the  gratification  of  which  they  find  a  natural  and 
pleasurable  outlet. 

But  the  habit  of  masturbation,  in  certain  other  cases,  acquires  a  power 
that  is  dominating  and  destructive  to  body  and  mind.  The  causes  of  this 
are,  either  an  innate  morbid  strength  of  the  reproductive  instinct,  or  much 
more  frequently  an  innate  weakness  of  the  controlling  faculties,  or  of  a 
lack  of  inherent  brain  stability,  or  of  an  incapacity  of  organic  repugnance 
to  what  is  unnatural.  Such  weaknesses  are  apt  to  occur  in  the  children 
of  neurotic  families.  From  the  beginning  the  habit  is  apt  to  take  a  deep 
hold  of  such  youths,  who  practise  it  to  the  point  of  exhaustion  of  all 
nervous  energy.  Even  when  this  occurs,  and  when  in  a  healthy  subject 
satiety  would  have  caused  disinclination  and  incompetence  in  the  youths 
to  whom  I  refer,  the  practice  is  not  stopped.  The  weaker  and  more 
nervous  he  gets  the  more  he  indulges  in  the  evil  habit,  till  the  point  of 
absolute  break-down  of  body  and  mind  is  reached.  It  seems  to  get  pos- 
session of  him  like  an  evil  spirit,  and  to  dull  and  paralyze  all  his  better 
feelings  and  his  natural  instincts.  The  heredity  and  temperament  are 
no  doubt  the  true  explanation  of  the  opposing  statements  that  are  con- 
fidently made,  on  the  one  hand,  that  this  habit  seldom  does  much  per- 
manent harm,  and,  on  the  other,  that  it  is  the  root  of  most  of  the  evils  of 
boyhood,  and  that  it  ruins  the  constitution  for  life  of  everyone  who  has 
ever  indulged  much  in  it.  Both  statements  are  so  far  true  of  boys  of 
different  constitutions  and  heredity.  It  is  somewhat  like  drinking  to 
excess ;  many  persons  can  do  this  at  times  without  risk  of  dying  the 
death  of  drunkards,  but  others  cannot  do  so  without  that  distinct  risk. 
It  is  no  doubt  true  that  the  restraint  and  management  of  the  reproduc- 
tive instinct  give  most  youths  most  trouble,  and,  as  medical  men,  the 
priests  of  the  body  and  the  teachers  of  the  truths  of  medico-psychology 
and  physiology,  we  can  often  help  them  by  our  counsel  and  our  knowl- 
edge. Unfortunately,  our  help  is  too  seldom  called  in.  We  are  about 
the  only  persons  who  can  help  a  youth  to  strike  the  happy  mean  between 
blissful  but  dangerous  ignorance  and  prurient  suggestive  knowledge.    We 


THE    INSANITY    OF    MASTURBATION.  343 

are  the  only  persons  who  can  judge  from  the  constitution  of  the  particular 
individual  how  much  he  ought  to  know,  and  what  risk  he  runs. 

As  a  complication  and  symptom  of  almost  every  form  of  insanity,  the 
habit  of  masturbation  is  lamentably  common.  The  melancholic,  the 
maniacal,  and  the  demented  patients  are  all  subject  to  its  indulgence. 
The  religious  ecstatics  who  have  direct  intercourse  with  the  Almighty, 
and  the  suicidal  melancholies  who  have  committed  crimes  beyond  re- 
demption— many  of  such  patients  of  both  sexes  are  masturbators.  In 
fact  it  is,  as  it  might  be  expected  to  be,  a  common  sign  of  the  loss  of  self- 
control  which  is  the  essence  of  mental  disease.  When  practised  to  excess 
by  the  insane,  it  certainly  tends  to  aggravate  mental  exaltation,  to  in- 
tensify depression,  to  lead  directly  towards  mental  enfeeblement,  and  to 
make  impulsive  tendencies  more  violent.  It  counteracts  the  effects  of 
treatment,  it  induces  relapses,  and  in  some  cases  prevents  the  recovery 
of  otherwise  curable  cases.  These  bad  results  are  most  frequently  and 
clearly  seen  in  the  adolescent,  hysterical,  puerperal,  epileptic,  and  con- 
genital forms  of  insanity,  and,  curiously  enough,  are  not  always  absent 
in  the  climacteric  and  senile  forms.  I  have  seen  a  senile  melancholic  of 
seventy-five  suffer  intensely  from  the  effects  of  the  practice.  In  all  these, 
however,  it  is  one  of  many  symptoms  of  mental  disease.  It  is  not  the 
chief  cause,  nor  is  it  the  chief  symptom  present,  and  it  does  not  color  the 
cases  so  as  to  give  them  any  distinct  mental  features. 

There  is  a  form  of  mental  disease,  however,  in  which  masturbation  is 
the  chief  cause  of  the  malady ;  it  is  the  chief  symptom  present,  and  it 
gives  the  whole  case  distinct  features.  This  has  been  named  the  insanity 
of  masturbation,  and  has  several  well-marked  features.  It  comes  on  in 
youth ;  it  generally  begins  by  an  exaggerated  and  morbid  self-feeling,  or 
by  a  shallow,  conceited  introspection,  or  by  a  frothy  and  emotional  re- 
ligious condition,  or  by  a  restless  and  unsettled  state,  with  foolish  hatch- 
ings of  philanthropic  schemes.  There  is  no  continuity  or  force  in  any 
train  of  thought  or  course  of  action.  Then  comes  a  melancholic  stage  of 
solitary  habits,  disinclination  for  company,  especially  that  of  the  other 
sex,  irritability,  variableness  of  mood,  hypochondriacal  brooding,  vacilla- 
tion, and  perversion  of  feeling  towards  near  relations.  Suicide  is  often 
thought  of,  and  oftener  talked  of,  but  masturbation  makes  most  of  its 
victims  too  cowardly  to  kill  themselves.  Then  an  acute  attack  follows, 
usually  of  a  maniacal  kind.  This  may  end  in  recovery,  or  may  run 
quickly  into  a  dementia  that  is  masturbational  in  character,  being  soli- 
tary, unsocial,  and  subject  to  impulses,  sometimes  homicidal — a  sort  of 
masturbational  hyperkinesia — all  these  being  incurable. 

With  these  mental  symptoms  there  are  usually  well-marked  bodily 
signs  of  the  disease.  The  patient  is  thin,  pale,  and  pasty,  with  a  cold, 
clammy  skin,  a  haggard  face,  and  an  eye  that  never  looks  straight  at 
you.  The  patient  has  weakness  in  the  back,  pains  in  the  head,  palpita- 
tion of  the  heart,  impaired  sight,  muscular  relaxation,  and  sometimes 
spermatorrhoea.  But  for  a  complete  record  of  the  feelings  and  symptoms 
of  the  youthful  masturbator  one  should  rather  go  to  those  shameful  quack 
advertisements  put  into  the  country  newspapers  than  to  medical  books. 
They  are  there  set  forth  at  large,  with  just  enough  concealment  to  make 
them  suggestive.     That  such  abominable  suggestions  of  evil  should  be 


344  THE    INSANITY    OF    MASTURBATION. 

allowed  to  be  scattered  broadcast  into  the  families  of  decent  people,  is  to 
me  one  of  the  standing  marvels  of  our  jurisprudence.  They  do  and  can 
do  no  good  to  anyone ;  they  aggravate  the  miseries  of  those  who  are 
suffering  from  the  minor  effects  of  this  vice  by  keeping  them  constantly 
before  their  minds ;  they  suggest  evil  thoughts  to  those  who  might  be 
free  from  them,  and  they  fatten  the  vilest  of  mankind.  I  verily  believe, 
and  I  speak  from  some  experience,  that  there  are  about  as  many  people 
made  insane  by  these  advertisements  and  the  pamphlets  sent  out  by  the 
advertisers,  as  by  the  habit  of  masturbation  itself. 

No  greater  condemnation  of  the  habit  of  masturbation  can  be  imagined 
than  the  changed  feelings  towards  the  other  sex  which  it  produces. 
Nature  there  as  elsewhere  punishes  the  breaker  of  her  laws.  Such  perver- 
sions of  feeling  are  very  interesting  to  the  medico-psychologist.  Instead 
of  the  true,  healthy  pleasure,  intense  as  it  is  natural,  of  social  and  family 
intercourse,  there  comes  a  self-conscious  bashfulness,  a  painful  conflict 
between  desire  and  repugnance,  a  suspicious  constraint,  and  a  guilty 
avoidance.  The  evil  to  him  who  evil  thinks  is  seldom  more  marked  than 
in  the  case  of  the  masturbator.  Any  method  through  which  this  habit 
could  be  lessened  among  our  rising  generation  would  certainly  do  great 
good;  life  would  be  elevated  in  a  large  degree,  self-respect  would  be 
increased,  social  intercourse  would  be  sweetened  and  its  pleasures  inten- 
sified ;  while  the  stings  of  self-accusation  and  remorse  would  be  far  fewer 
in  after-life. 

The  ordinary  type  of  masturbational  insanity  is  illustrated  in  many 
of  its  chief  features  in  this  cavse : 

J.  W.,  set.  22,  a  young  man  of  a  naturally  cheerful  and  frank  disposi- 
tion and  steady  habits,  and  with  a  good  family  history  so  far  as  known. 
When  an  infant  he  was  delicate,  and  was  supposed  to  have  been  threatened 
with  hydrocephalus,  and  he  had  convulsions  during  his  first  dentition. 
Those  symptoms  no  doubt  implied  a  neurotic  heredity.  Since  then  his 
health  had  been  good  up  to  his  present  malady.  For  yeai-s  after  puberty 
he  indulged  in  the  habit  of  masturbation  to  a  great  excess.  He  gradually 
fell  off  in  looks  and  bodily  vigor,  and  mentally  he  became  changed.  He 
got  egotistical,  hypochondriacal,  changeable  in  his  resolutions,  fanciful, 
and  unsocial.  Those  symptoms  did  not  come  on  all  at  once,  but  took 
years  fully  to  develop.  They  seemed  to  follow  a  diminution  of  nervous 
tone  and  general  bodily  strength.  At  last  the  mental  depression  stood 
out  from  all  the  other  mental  symptoms.  It  was  hypochondriacal  in 
character.  He  thought  his  sexual  organs  were  "all  gone,"  that  his  chest 
was  "falling  in;"  he  complained  of  pains  in  his  back  and  in  his  head, 
and  that  his  back  was  "very  weak."  When  he  was  about  twenty-two 
he  made  several  feeble  ineffectual  attempts  to  commit  suicide,  both  by 
hanging  and  strangulation.  He  was  then  sent  to  the  asylum.  He  was 
pale,  his  muscles  flabby,  his  skin  moist  and  clammy,  his  tongue  coated, 
his  bowels  costive,  and  his  expression  depressed  and  furtive.  He  never 
could  look  one  in  the  face.  Masturbators  seldom  can :  but  do  not  put 
down  every  insane  person  who  cannot  look  you  in  the  face  as  necessarily 
a  masturbator.  His  genital  organs  were  loose  and  flabby,  and  his  testicles 
tender.  He  says  he  suffers  from  spermatorrhoea,  but  has  now  no  natural 
sexual  desire.     Yet  his  mind  runs  on  the  subject,  and  it  is  one  of  the 


THE    INSANITY    OF    MASTURBATION.  345 

great  sources  of  his  mental  depression  that  he  has  lost  his  virility.  He 
thought  himself  very  weak  indeed,  and  that  he  could  not  get  better.  He 
said  he  would  like  to  put  an  end  to  himself,  and  yet  would  not  like  to  do 
so.  He  was  ordered  compound  cod-liver  oil  emulsion  with  hypophosphites, 
strychnine,  much  milk  diet,  fresh  air,  cold  sponging,  and  a  little  garden 
work.  He  was  never  done  making  attempts  to  strangle  himself  with  his 
necktie.  In  about  three  months  he  was  distinctly  improved.  His  whole 
"tone"  of  mind,  general  nervous  action,  and  of  nutrition,  was  better. 
But  he  could  scarcely  be  prevented  from  talking  about  himself  and  his 
ailments,  imaginary  and  real.  He  wanted  medical  books  to  read  about 
his  case,  and  said  he  had  bought  and  read  all  the  quack  literature  on 
"nervous  depression,"  etc.,  he  could  lay  his  hands  on,  which  always 
made  him  worse.  He  ate  and  slept  well,  and,  it  was  feared,  continued 
his  evil  habit,  but  not  to  any  great  extent.  In  six  months  he  had  gained 
in  weight,  could  employ  himself  more,  and  was  much  more  cheerful.  He 
was  sent  home  half-cured,  on  the  theory  that  he  would  there  have  more 
motives  to  rouse  himself  and  go  to  work.  That  he  did,  and  after  a  year 
he  was  pretty  well. 

Here  is  the  extract  from  a  very  instructive  letter  to  me  from  J.  X.,  a 
lad  of  twenty-two,  who  for  two  years  had  been  hypochondriacal  and  un- 
settled, and  alternately  elevated  and  depressed  in  mind :  "  If  I  had  come 
like  a  man  to  the  point,  and  told  the  doctors  what  was  the  real  matter 
with  me  (but  in  fact  I  really  did  not  know  myself  till  some  time  ago).  I 
have  committed  masturbation  for  some  years  back,  and  sometimes  as  often 
as  three  times  a  day.  I  am  sure  I  cannot  explain  myself  nor  give  account 
of  such  conduct.  Sometimes  I  felt  so  uneasy  at  my  work  that  I  would 
go  to  the  W.C.  to  do  it,  and  it  seemed  to  give  me  ease,  and  then  I  would 
work  like  a  hatter  for  a  whole  week  till  the  sensation  overpowered  me 
again.  I  have  been  the  most  filthy  scoundrel  in  existence.  I  did  not 
know  at  that  time  what  harm  I  was  doing  myself,  although  I  knew  I  was 
doing  something  filthy  and  wrong,  and  many  are  the  times  I  have  made 
resolutions  to  put  a  stop  to  such  conduct,  and  sometimes  managed  for  a 
month,  not  more.  Owing  to  my  trade  I  fell  in  with  lots  of  girls,  but 
never  cared  much  about  speaking  to  them,  owing,  I  believe,  to  me  doing 
that  filthy  practice."  He  describes  how  he  tried  to  have  connection  with 
a  girl  with  whom  he  thought  he  had  at  last  fallen  in  love,  and  that  he 
failed,  and  that  he  was  disgusted  with  himself  and  her.  "  This  and  other 
things,  with  my  business  not  getting  on,  I  was  most  determined  to  end 
my  miserable  career."  He  then  described  how  he  took  laudanum,  and 
how  he  felt  afterwards.  "  I  hope  for  my  father's  sake  you  will  give  me 
your  advice,  not  for  my  sake,  for  I  am  not  worth  taking  notice  of.  Some 
time  ago,  when  I  was  wondering  if  there  was  any  seed  left  in  me  at  all, 
I  committed  masturbation,  but  had  to  do  it  for  a  considerable  time,  and 
after  some  did  come  it  was  dull  in  the  color  and  scanty,  and  instead  of  a 
pleasant  sensation  it  pained  me."  After  a  month  or  two  this  lad's  de- 
pression passed  oiF,  and  as  his  bodily  health  improved  he  became  ex- 
citable, restless,  egotistical,  and  irritable.  This  lasted  for  a  time,  and  he 
then  appeared  to  get  quite  well  in  mind  and  body. 

I  have  known  many  instances  of  the  habit  of  masturbation  being  taken 
to  without  any  teaching,  and  in  some  cases  at  incredibly  early  ages.     I 


846  THE    INSANITY    OF    MASTURBATION. 

have  now  a  patient,  J.  Y.,  who  is  always  nervous,  diffident,  unable  to 
earn  his  own  livelihood,  tending  to  be  depressed  and  suicidal  at  times, 
and  egotistically  irritable,  conceited,  and  impracticable.  At  other  times, 
every  now  and  then,  he  gets  so  depressed  that  he  has  to  be  sent  into  the 
asylum,  or  comes  into  it  of  his  own  accord.  This  man  has  frequently 
assured  me,  when  at  his  best  mentally,  that  he  acquired  the  habit  when 
he  was  six  years  of  age,  that  no  one  taught  him,  that  almost  ever  since 
it  has  been  his  bane  and  curse,  that  he  knows  as  well  as  anyone  how 
wrong  it  is  to  practise  it,  and  that  it  does  him  infinite  harm  in  body  and 
mind ;  and  he  says  that  at  times  his  mind  is  filled  with  disgust  at  the 
filthy  nature  of  the  practice,  and  despair  at  the  hold  it  has  acquired  over 
him.  Yet,  in  spite  of  all  this,  he  cannot  stop  it,  the  morbid  fascination 
over  his  mind  is  so  poAverful.  He  describes  it  as  like  a  fate  that  he  must 
yield  to,  an  involuntary  act  over  which  his  will  seems  to  have  no  control, 
though  the  practice  of  it  is  at  times  painful  and  not  pleasurable.  Yet  I 
never  saw  any  case  in  which  suitable  treatment,  control,  fresh  air,  hard 
work  in  the  garden,  and  suitable  food,  had  so  good  an  efiect.  After  two 
or  three  months  he  became  another  man,  lost  to  a  great  extent  his  hang- 
dog look,  his  depression,  his  suspicions,  and  hypochondriacal  notions,  got 
fresher  and  fatter,  and  had  less  marked  inclination  towards  his  evil  habit. 
But  it  has  unmanned  him,  and  made  him  quite  unfit  for  facing  the  world. 
So  anxious  was  he  to  be  cured,  that  he  has  had  himself  castrated  lately. 
This  has  stopped  the  tendency  to  masturbation,  but  mentally  some  de- 
pression and  "nervousness"  remain. 

There  is  no  doubt  that  the  act  of  masturbation  is  often  not  only  done 
involuntarily  and  contrary  to*  every  inclination  of  the  will,  but  it  may 
also  be  unconsciously  done.  I  have  seen  it  done  in  the  unconscious  period 
immediately  after  an  epileptic  fit ;  and  in  the  unconscious  stages  of  acute 
mania  and  excited  melancholia  it  is  most  common. 

Many  of  the  cases  do  not  recover.  I  have  many  patients  in  the 
asylum,  of  which  this  is  a  type:  K.  A.,  aet.  37.  Began  to  masturbate 
at  fifteen,  and  has  continued  the  practice  to  excess  ever  since.  He  became 
80  insane  as  to  require  to  be  sent  to  the  asylum  at  twenty,  after  a  year  or 
two  of  restless  egotism  and  selfish  hypochondriasis,  varied  by  spurts  of 
equally  selfish  emotional  religionism  at  home.  He  at  first  could  reason, 
read,  and  occupy  himself  a  little,  but  as  the  habit  has  gone  on  his  mental 
power  has  gradually  weakened,  his  social  instincts  have  become  extin- 
guished, his  self-respect  and  all  his  sense  of  decency  have  become  utterly 
lost.  He  is  now  a  slouching,  untidy-looking  fellow,  with  a  hang-dog 
look,  who  can  never  be  got  to  look  you  in  the  face,  who  never  reads  or 
speaks  to  anyone,  cares  nothing  for  his  relatives,  has  no  energy,  looks 
pale,  red-nosed,  and  pinched.  And  yet  he  is  not  quite  demented  in  the 
ordinary  sense.  He  is  coherent,  and  you  find  his  memory  is  not  gone 
when  you  talk  to  him. 

The  general  principles  of  treatment  of  masturbational  insanity  unques- 
tionably are  to  brace  up  the  youth  bodily,  mentally,  and  morally.  In 
the  first  place,  the  diet  should  be  unstimulating  and  fattening.  It  is 
strange  that  the  physiological  inductions  of  the  old  Catholic  Church  as 
to  the  dietetic  management  of  the  nisus  generativus  and  its  volitional 
control  have  been  so  neglected  by  modern  physicians,  founded  as  they 


THE    INSANITY    OF    MASTURBATION.  347 

were  on  the  experiences  of  the  terrific  conflict  with  nature  that  was 
implied  in  the  early  Christian  theory  that  sexual  desire  was  more  or  less 
of  the  devil,  and  should  be  eradicated  and  not  merely  regulated  by  all 
men  who  wished  to  attain  a  high  religious  ideal ;  and  in  the  later  rule  of 
priestly  celibacy.  My  own  belief  is  that  the  Catholic  view  of  repression 
and  eradication  being,  for  the  sake  of  argument,  granted,  almost  every 
rule  of  the  church  as  to  food  and  fasting,  and  every  practice  of  the  mon- 
astic orders,  and  every  conventual  regulation,  is  a  correct  physiological 
principle.  Translated  from  religious  into  physiological  language,  they 
may  be  summed  up  thus — Strengthen  the  power  of  inhibition  bodily  and 
mental.  Practise  the  habit  of  mental  concentration  and  abstraction  from 
certain  lines  of  thought.  Cultivate  enthusiasm  about  ideals.  Find  ideal 
outlets  for  the  affective  and  social  faculties  other  than  sexual  choices. 
Sleep  only  under  such  conditions  and  so  long  as  to  recuperate  lost  energy 
and  tissue,  and  not  to  accumulate  energy  that  there  might  be  a  difficulty 
in  getting  rid  of  short  of  sexually.  Eat  only  non-stimulating  and  fat- 
tening food,  and  that  in  moderation,  with  periodic  abstentions  to  use  up 
spare  material  in  the  body.  Avoid  flesh,  as  the  incarnation  of  rampant, 
uncontrollable  force,  sexual  and  otherwise.  Be  much  in  the  open  air,, 
and  work  hard.  Finally,  so  fill  up  and  systematize  the  time  that  none 
is  left  for  day-dreaming.  Now,  such  are  undoubtedly  the  proper  rules 
with  which  to  treat  the  habit  of  masturbation  and  its  mental  and  bodily 
effects.  If  we  add  to  those  the  medical  means  of  cold  baths,  tonics, 
games,  family  life,  and  a  course  of  bromide  of  potassium,  our  resources 
are  pretty  nearly  exhausted.  I  would  certainly  avoid  local  treatment  or 
mechanical  appliances  as  a  general  rule.  It  is  no  doubt  possible  to  make 
the  organs  of  generation  so  sore  that  excitation  of  them  becomes  im- 
possible ;  and  if  the  patient's  imagination  has  disappeared  through  his 
dementia,  this  rest  from  constant  nervous  exhaustion  may  be  taken 
advantage  of  to  feed  him  up  and  get  him  into  habits  of  working,  and 
into  a  comfortable  dementia.  That  is  a  good  thing,  but  it  only  applies, 
in  my  experience,  to  those  whose  mental  power  is  already  gone.  For 
the  masturbator  whose  mental  energy  is  still  there  to  some  extent,  or 
only  temporarily  suspended,  such  mechanical  expedients  and  obviators 
of  present  indulgence  only  concentrate  the  attention  on  the  function,  and 
cause  desires  that  are  intense  in  proportion  to  the  present  impossibility 
of  gratifying  them.  Do  not  recommend  marriage  as  a  remedy.  It  is  a 
most  dangerous  experiment.  It  is  apt  to  be  followed  by  sexual  repug- 
nance in  a  short  time,  and  the  last  state  is  worse  than  the  first,  two 
persons'  happiness  being  destroyed  instead  of  one. 

There  have  been  forty-six  cases  that  I  have  diagnosed  as  masturbational 
insanity  sent  to  the  Royal  Edinburgh  Asylum  during  the  past  nine  years, 
and  of  these  sixteen,  or  twenty-five  per  cent.,  have  made  good  recoveries, 
doing  their  work  in  life  well  afterwards.  Some  of  the  cases  I  have  been 
consulted  about  out  of  the  asylum,  and  some  of  those  I  have  had  under 
my  care  in  it,  are  now  occupying  responsible  positions  and  doing  first-rate 
work  in  the  world.  Some  are  the  fathers  of  families.  There  is  no  ground 
whatever  for  such  an  unfavorable  prognosis  in  any  case  I  have  met 
with  as  some  medical  men  in  the  habit  of  giving,  and  there  is  no  sort  of 
ground  for  thinking  there  is  any  special  risk  of  relapse,  or  any  special 


348  THE    INSANITY    OF    MASTURBATION. 

form  of  nervousness,  that  will  necessarily  stick  to  a  masturbator  all  his 
life.  Eighteen  more  of  the  cases  left  the  asylum  more  or  less  improved, 
while  twelve  still  remain  there  hopeless,  incurable,  and  degraded. 

One  warning  I  have  to  give  before  I  have  done  with  this  disagreeable 
subject.  It  is  this :  not  to  believe  all  the  melancholic  patients  who 
attribute  their  bad  symptoms  to  the  former  practice  of  this  vice  in  youth. 
This  is  a  common  self-accusation.  In  most  instances  it  is  a  mere  delu- 
sion, like  so  many  other  melancholic  delusions,  founded  on  a  morbid 
exaggeration  of  the  consequences  of  departures  from  strict  rectitude.  It 
just  amounts  to  the  same  thing,  psychologically,  as  such  common  melan- 
cholic fancies  that  the  loss  of  control  over  the  temper,  and  calling  a 
friend  a  bad  name  ten  years  ago  is  an  unpardonable  sin,  that  not  going 
to  church  on  a  certain  Sunday  will  be  punished  by  eternal  damnation,  or 
that  a  gonorrhoea  in  youth  has  so  polluted  the  blood  that  all  the  offspring 
are  diseased,  and  that  death  must  ensue.  The  real  significance  of  mas- 
turbation in  each  case  must  be  carefully  inquired  into,  and  the  facts 
ascertained  before  a  conclusion  as  to  its  effects  is  formed. 


LECTURE    XV. 

PUEKPEKAL  INSANITY— LACTATIONAL  INSANITY— THE 
INSANITY  OF   PKEGNANCY. 

Childbirth,  nursing,  and  pregnancy  in  women  are  liable  to  act  as  the 
exciting  causes  of  attacks  of  mental  disease.  In  importance  and 
frequency  they  stand  in  the  order  in  which  I  have  placed  them.  For 
many  reasons  it  is  especially  necessary  that  the  general  practitioner  of 
medicine  should  be  well  acquainted  with  these  forms  of  insanity,  for 
they  all  occur  at  a  time  when  he  is  apt  to  be  attending  the  patient 
for  other  reasons,  they  all  can  under  favorable  circumstances  be  treated 
at  home  in  many  individual  cases,  and  it  is  well  so  to  treat  them  when 
possible.  They  are  all  very  curable  forms  of  mental  disease,  and,  when 
cured,  they  are  not  apt  to  leave  any  traces  of  mental  weakness  or 
obliquity  behind.  The  patients  can  resume  their  work  and  places  in  the 
family  and  society,  and  be  as  if  they  had  never  been  ill.  The  three 
forms,  though  having  much  in  commom,  yet  diiFer  in  so  many  respects 
that  I  must  take  them  separately. 

The  advantage  and  the  practical  necessity  of  classifying  mental 
diseases  in  other  ways  than  according  to  the  mental  symptoms  present, 
are  especially  seen  in  these  three  forms  of  mental  disease.  To  know  that 
a  case  is  one  that  has  begun  after  recent  childbirth  is  to  know  far  more 
about  it  than  to  know  it  as  mania  or  melancholia  for  treatment  and  for 
prognosis.     There  is  no  practical  physician  but  will  admit  this. 


PUERPERAL   INSANITY. 

I  do  not  know  any  event  that  can  occur  in  a  family,  short  of  death, 
that  is  so  great  a  shock  to  all  who  have  to  do  with  it,  as  for  a  new-made 
mother  of  a  first-born  child  to  become  suddenly  maniacal,  and  require  to 
be  sent  to  an  asylum.  One  of  the  most  joyous  times  of  life  is  made  full 
of  fearful  anxiety,  and  the  strongest  affection  on  earth  is  then  often 
suddenly  converted  by  disease  into  an  antipathy  ;  for  the  mother  not  only 
"forgets  her  sucking  child,"  but  often  becomes  dangerous  to  its  life. 
And  few  things  are  more  pleasant  than  to  see  the  restoration  of  the 
mother  back  to  all  that  makes  her  life  worth  having. 

Puerperal  insanity  is  technically  limited  to  the  mental  disease  that 
occurs  within  the  first  six  weeks  after  confinement.  By  far  the  majority 
of  the  cases,  and  by  far  the  most  acute  and  characteristic  cases,  occur 
within  the  first  fortnight.  It  is  a  very  common  form  of  mental  disease, 
for  five  per  cent,  of  all  the  cases  of  insanity  among  women  are  puerperal, 
and  I  think  that  it  is  a  low  estimate  that  one  in  every  four  hundred 


350  PUERPERAL    INSANITY. 

labors  is  followed  by  it.  In  one-half  of  the  patients  the  disease  begins 
within  the  first  Aveek  after  confinement,  and  in  three-fourths  of  them  within 
the  first  fortnight.  In  regard  to  the  cause  of  the  disease,  therefore,  it  is 
definite  and  clear.  The  accompaniments  of  childbirth  produce  it.  The 
great  physiological  cataclysm  itself,  the  pains  of  labor,  the  excitement 
mental  and  bodily,  the  exhaustion,  the  loss  of  blood,  the  open  bloodvessels 
liable  to  absorb  every  septic  particle,  the  sudden  diversion  of  the  stream 
of  vital  energy  from  the  womb  to  the  mammae,  these  together  or  separately 
are  the  causes  that,  acting  on  an  unstable  brain  hereditarily,  set  up  one 
of  the  most  violent  mental  storms  that  the  physician  has  ever  to  treat. 
And  it  comes  on  very  suddenly  in  most  cases.  The  mother  looks  self- 
absorbed  and  dull.  She  does  not  take  such  notice  of  the  baby  as  is  usual, 
or  such  interest  in  what  is  going  on.  She  does  not  answer  questions 
readily.  She  does  not  eat,  and  she  does  not  sleep  at  night.  Next 
morning  she  is  restless.  Her  eyes  are  brilliant.  She  seems  to  have  no 
sense  of  exhaustion.  She  expresses  foolish  fancies,  such  as  that  she  is 
poisoned,  that  there  is  some  one  under  the  bed.  She  takes  a  violent 
dislike  to  the  doctor,  or  the  nurse,  or  the  child.  She  begins  to  chatter 
all  the  time,  and  her  talk  becomes  less  and  less  connected.  She  is  erotic, 
joyous,  scolding,  and  perfectly  incoherent  all  within  a  few  hours.  She 
gets  violent,  and  needs  to  be  held  in  bed ;  impulsively  and  without  set 
intent  she  attempts  suicide,  or  tries  to  kill  her  baby,  or  to  throw  herself 
out  of  the  window.  She  seems  as  if  she  had  a  supernatural  strength. 
Yet  when  you  feel  her  pulse  it  is  weak  and  thready,  her  face  looks 
haggard,  her  temperature  has  risen  to  100°  or  more,  her  womb  is  tender 
on  pressure  over  the  abdomen,  and  she  will  not  look  at  food.  Her  lochia 
have  first  become  somewhat  ofiensive  and  then  stopped.  Her  skin  is 
moist  and  clammy.  She  soon  ceases  to  know  those  about  her,  calls  her 
friends  by  other  names,  and  strangers  by  the  names  of  her  friends.  Her 
lips  and  tongue  show  signs  of  getting  dry.  If  she  is  poor  or  cannot  get 
plenty  of  nursing  or  medical  attendance,  she  must  be  sent  to  the  nearest 
asylum,  and  the  sooner  the  better,  for  she  needs  all  that  the  asylum  can 
do  for  her.  She  needs  to  be  fed  at  once,  nolens  volens  (by  means  of  the 
rubber  nose-tube  if  she  will  not  take  it  otherwise),  with  plenty  of  milk 
and  eggs,  and  soups,  and  wine,  and  this  needs  to  be  repeated  every  hour 
or  two.  Let  her  alone,  and  she  dies  or  becomes  demented.  Narcotize 
her  with  morphia,  and  her  secretions  dry,  her  tongue  gets  furred  and 
hard,  and  her  antipathy  to  food  is  doubled.  But  nurse  and  feed  her  well 
by  night  and  day,  striking  the  happy  mean  between  undue  restraint  and 
too  great  activity,  get  her  out  for  a  little  in  the  open  air  in  a  day  or  two, 
keep  up  the  attendance,  and  in  a  week  she  will  show  a  little  sign  of 
mental  coherence,  in  a  fortnight  her  appetite  will  have  returned,  her  pulse 
will  be  stronger,  her  temperature  will  have  fallen  to  normal,  and  she  will 
walk  out  herself  without  tearing;  her  clothes  or  throwing  herself  about. 
In  a  month  she  will  be  knittinor  a  stockino;,  and  will  know  her  friends 
when  they  come  to  see  her.  Within  three  months  she  is  well — a  joyous 
mother,  in  her  right  mind,  clasping  her  child,  the  Avhole  of  the  disturbed 
mental  period  seeming  like  a  dream  to  her,  that  is  very  soon  altogether 
forgotten  in  her  new  duties  and  delights. 

Although  puerperal  insanity  is  more  frequent  in  first  than  in  subsequent 


PUERPERAL    INSANITY.  351 

confinements,  yet  it  is  common  enough  in  the  latter,  and  I  have  known  a 
woman,  K.  B.,  who  had  six  attacks  of  puerperal  insanity,  having  one 
after  the  birth  of  each  child  she  had,  and  she  recovered  from  them  all. 
But  this  is  the  exception.  The  woman  that  cannot  liave  a  baby  without 
having  also  puerperal  insanity,  and  who  persists  in  having  babies,  usually 
remains  more  or  less  permanently  affected  after  the  third  or  fourth  attack. 

The  ordinary  causes  of  mental  disease  contribute  as  predisposing  causes 
towards  puerperal  insanity.  Poverty  and  want  of  proper  attendance 
during  childbirth,  and  having  to  get  out  of  bed  and  to  work  too  soon,  I 
have  seen  bring  it  on.  The  shame  and  mental  distress  usually  attending 
the  birth  of  illegitimate  children  make  it  twice  as  common  then  as  after  the 
birth  of  legitimite  children.  I  have  several  times  seen  a  sudden  mental 
shock  act  as  the  proximate  cause  of  the  disease  in  women  who  seemed  to 
be  doing  well  in  childbed.  I  once  saw  the  news  of  the  death  of  the 
patient's  father  send  a  woman,  in  the  second  week  after  confinement,  into 
acute  mania  within  a  few  hours.  But  such  moral  or  other  causes  are 
not  at  all  necessary  to  produce  the  disease,  over  and  above  the  puerperal 
condition.  In  by  far  the  majority  of  the  cases  there  is  no  other  cause. 
It  occurs  in  ladies  with  every  comfort  and  attendance  as  well  as  among 
the  poor. 

Most  of  the  recoveries  from  puerperal  insanity  are  gradual  ones.  We 
do  not  commonly  find  those  sudden  wakenings  up  from  an  acute  delirious 
condition  into  coherence,  self-control,  and  sanity  that  we  sometimes  see  in 
other  forms  of  mental  disease.  That  is,  in  my  opinion,  one  of  the  reasons 
why  the  recoveries  are  apt  to  be  complete  and  permanent.  I  do  not  like 
very  sudden  recoveries  in  any  form  of  mental  disease,  because  they  are 
not  so  apt  to  be  permanent,  and  they  indicate  an  essentially  unstable 
dynamical  condition  of  the  convolutions.  I  am  never  quite  satisfied 
about  the  recovery  of  a  puerperal  case  until  the  woman  gets  stout  and 
strong,  and  until  her  menstruation  has  returned  and  become  regular. 

The  following  is  a  typical  case  of  puerperal  insanity  of  the  acute  but 
not  delirious  kind:  K.  C,  aet.  19,  a  hard-working  domestic  servant,  with 
no  known  heredity  to  the  neuroses.  Though  she  came  of  a  "  respectable" 
family,  she  had  an  illegitimate  child  born  in  the  Maternity  Hospital.  Her 
labor  was  not  specially  severe,  and  she  did  well  for  three  days.  Then, 
without  any  new  cause,  she  got  dull  and  took  no  notice  of  her  child  or  of 
anything  else;  in  a  few  hours  she  began  to  laugh  hysterically,  then  she 
got  more  excited,  restless,  noisy,  and  talked  incoherently  about  religious 
matters.  She  did  not  sleep,  and  in  four  days  she  had  to  be  sent  to  the 
asylum.  On  admission  she  was  much  excited  and  greatly  exalted  in 
mind.  She  mistook  the  identity  of  everyone  near  her.  She  sung  on  at 
the  pitch  of  her  voice  in  a  rhyming  way,  putting  her  delusions  and  con- 
versation Avith  herself  into  rhyme.  Her  ideas  and  currents  of  thought 
were  always  changing.  She  looked  pale.  Her  pulse  was  weak,  and  her 
temperature  was  98.2°.  She  did  not  sleep  for  the  first  week  at  all.  She 
was  restless,  singing,  loquacious,  and  delusional  all  that  time.  She  was 
put  on  all  sorts  of  very  nourishing  food,  especially  custards  of  milk  and 
eggs,  and  she  was  taken  out  into  the  open  air  for  a  short  time  each  day 
after  the  first  two  days.  She  began  to  sleep  in  a  week,  and  after  that 
slept  more  or  less  regularly.     She  continued  restless,*  good-natured,  and 


852  PUEEPERAL    INSANITY. 

talkative,  destructive  to  her  clothes  at  times,  foil  of  boisterous,  half  inco- 
herent fun,  and  unable  to  settle  to  do  any  work  for  two  months.  She 
gained  in  weight  all  that  time,  eating  well  and  spending  much  time  in 
the  open  air.  Then  she  began  to  work,  was  put  to  rough  scrubbing  and 
laundry  work,  so  getting  rid  of  her  excessive  muscular  energy.  In  three 
months  she  was  fattening,  quieting,  and  working  hard.  In  four  months 
after  admission  she  was  stout,  sensible,  and  well  in  mind  and  body, 
menstruation  having  begun,  and  she  was  then  sent  back  to  her  situation, 
which  had  been  kept  open  for  her  in  consideration  of  her  previous  good 
conduct. 

Some  of  the  very  acute  cases  with  a  high  temperature  and  most  un- 
favorable symptoms  make  good  recoveries,  if  proper  treatment  is  adopted 
soon  enough,  as  in  this  case: 

K.  D.,  set.  27.  A  married  woman  of  correct  habits,  with  no  known 
heredity  to  insanity;  her  first  child.  Her  labor  was  natural.  Things 
went  on  well  for  a  week ;  then,  without  apparent  cause,  she  began  to 
complain  of  headache  and  costiveness.  She  got  restless  and  sleepless, 
then  next  day  she  became  foolishly  talkative  and  erotic,  and  neglected 
the  child.  The  lochia  and  milk  stopped.  She  refused  food  absolutely, 
getting  worse  day  by  day,  and  becoming  Aveaker  fast.  She  wanted  a 
razor  to  cut  her  throat,  and  threw  a  tumbler  at  her  husband,  but  was  not 
very  suicidal  or  dangerous.  In  two  or  three  days,  she  was  absolutely 
delirious  and  incoherent,  but  was  not  sent  to  the  asylum  till  seven  days 
after  the  mental  symptoms  appeared.  On  admission,  she  was  greatly 
excited,  shut  her  eyes  tightly,  singing  and  swearing,  and  using  the  most 
obscene  language  continuously.  She  seemed  to  imagine  she  was  in  hell 
and  surrounded  by  devils  at  one  time,  and  she  had  exalted  fancies  at  other 
times.  She  did  not  sleep  at  night,  and  with  the  utmost  difficulty  was  got 
to  take  some  little  liquid  nourishment.  Her  temperature  was  found  to 
be  100°.  Her  pulse  was  very  thready,  her  skin  clammy.  She  was 
constantly  jerking  and  throwing  her  limbs  about,  her  tongue  tending  to 
be  dry,  and  her  general  bodily  condition  one  of  great  exhaustion.  She 
got  ten  grains  of  ohloral  and  slept  three  hours  the  first  night.  Next  day 
she  was  fed  by  the  nose-tube  with  a  custard  containing  three  eggs,  one 
pint  of  milk  and  cream,  some  strong  beef-tea,  four  ounces  of  port  wine,  and 
five  grains  of  quinine.  This  acted  as  a  soporific,  and  she  slept  well  most  of 
the  afternoon.  After  awaking,  she  was  less  excited,  but  confused  in 
mind.  This  mode  of  feeding  was  continued  twice  a  day.  On  the  fourth 
evening  after  admission  her  temperature  was  103.8°,  but  mentally  she 
seemed  to  have  a  lucid  interval,  being  rational,  and  she  then  took  her 
food.  Some  fetid  lochial  discharge  made  its  appearance  at  this  time. 
Weak  carbolic  vaginal  syringing  was  used.  On  the  sixth  day  she  be- 
came again  acutely  maniacal,  with  a  morning  temperature  of  101.4°,  an 
evening  temperature  of  102.8°,  and  she  had  to  be  fed  Avith  the  tube.  On 
the  eighth  day  she  was  sleepy  and  quiet,  took  her  food,  and  after  two  days 
of  confosion  of  mind  got  quite  sane,  and  remained  so,  remembering 
nothing  of  what  had  taken  place  during  her  illness.  I  allowed  her 
friends  to  remove  her  on  the  twenty-first  day,  she  having  a  good  home, 
where  her  bodily  strength  could  be  got  up  as  well  as  in  the  asylum,  and 
she  has  kept  well  ever  since. 


PUERPERAL    INSANITY.  363 

Puerperal  insanity  is  that  form  of  mental  disease  in  which  we  are  least 
apt  to  have  relapses  after  the  patients  have  once  fairly  become  convales- 
cent; and  I  have  less  hesitation  in  letting  relations  remove  them  from 
the  asylum  at  an  early  period,  if  they  have  good  homes  and  attendance, 
than  in  any  other  form.  In  this  case  of  K.  D.,  I  looked  on  the  feeding 
at  once  as  having  saved  her  life.  The  immediate  sedative  and  soporific 
effects  of  filling  the  stomach  with  food  and  stimulants  were  most  striking, 
and  I  very  often  see  this.  There  is  no  doubt  whatever  in  my  mind  that 
alcoholic  stimulants  along  with  food  are  of  the  utmost  service  in  many 
cases  of  puerperal  insanity,  their  good  effects  being  more  immediate,  in 
my  opinion,  than  in  any  other  form  of  mental  disease. 

In  the  case  of  patients  being  attacked  with  puerperal  insanity  who 
have  good  homes,  especially  if  they  are  in  the  outskirts  of  a  town  or  in 
the  country,  and  can  get  constant  medical  attendance  and  good  trained 
nursing,  they  may  often  be  treated  at  home.  I  lately  attended  a  lady  in 
consultation,  K.  E.,  who,  within  ten  days  after  confinement,  became 
sleepless  and  restless,  took  antipathies  to  her  doctor,  monthly  nurse,  and 
child,  mistook  the  identities  of  all  those  about  her,  calling  me  by  the 
name  of  an  old  friend,  who  had  a  temperature  of  101°,  with  slight 
uterine  tenderness  and  absolute  refusal  of  food,  being  most  troublesome 
and  difficult  to  manage.  I  sent  a  first-rate  attendant  from  the  asylum  in 
addition  to  the  ordinary  nurse  and  servants,  and  she  was  fed,  controlled, 
nursed,  taken  out,  and  got  through  her  attack  in  about  six  weeks,  just  as 
well  as  if  she  had  been  sent  to  an  asylum.  But  the  strain  and  responsi- 
bility on  relations,  attendants,  and  nurses  were  no  doubt  most  severe,  and 
they  were  nearly  exhausted  by  the  time  the  patient  had  recovered. 

The  following  case  had  a  melancholic  character  throughout,  though 
acute -and  curable:  K.  F.,  aet.  23.  No  heredity  ascertained.  Had  been 
a  strong  healthy  young  woman,  and  had  had  one  child  previously  eighteen 
months  ago.  This  child  took  a  convulsive  attack  within  a  week  after  her 
second  confinement,  and  the  fright  and  shock  of  this  seemed  at  once  to 
upset  her  mentally,  for  she  was  within  a  few  hours  afterwards  incoherent 
and  maniacal.  She  was  put  under  chloroform,  and  got  morphia  in  quan- 
tities, and  was  kept  under  the  chloroform  almost  continuously  for  a  week. 
This  deadening  of  the  brain  functions  did  not  cure  the  maniacal  condi- 
tion; whenever  she  awoke  she  was  as  bad  as  ever.  But  next  week  she 
was  almost  sensible.  After  that  the  acutely  maniacal  condition  returned, 
and  after  a  week  of  it  she  was  sent  to  the  asylum.  She  was  then 
intensely  depressed,  looking  afraid  of  something  going  to  happen  to  her, 
imagining  that  something  was  in  the  bed.  Her  memory  was  gone.  She 
did  not  know  her  husband,  and  mistook  the  identity  of  the  people  about 
her.  She  had  hallucinations  of  hearing.  Her  pulse  was  120,  feeble  and 
intennittent.  Her  temperature  104.2°.  Altogether  she  was  very  ex- 
hausted. She  was  fed  hourly  with  custards  and  sherry  in  large  quantity. 
On  the  second  day  after  admission,  her  temperature  suddenly  sunk  to 
97.2°  and  her  pulse  to  78,  and  this  was  coincident  with  the  appearance 
of  a  profuse  bloody  lochial  discharge.  Mentally  she  was  also  much 
improved,  though  not  quite  rational.  Towards  evening  she  became  rest- 
less, and  had  the  hallucinations  of  hearing  again,  though  her  temperature 
was  only  98°.     She  did  not  sleep,  and  was  very  depressed  and  restless 

23 


354  PUERPERAL    INSANITY, 

next  day,  saying  she  was  a  great  prodigal  and  a  sinner,  but  took  food 
voluntarily,  though  needing  forcing  to  take  enough.  The  temperature 
never  again  rose  above  100°.  She  frequently  showed  the  morbid  brain 
tendency  of  repeating  a  word  said  in  her  hearing  over  and  over  again, 
e.g.,  Zachariah-iah-iah-iah — Zach-ire."  She  was  well  fed  and  nursed, 
and  usually  slept  about  three  or  four  hours  a  night.  In  a  week  •  she  was 
able  to  be  taken  out  into  the  garden,  and  slept  much  better  after  this.  In 
ten  days,  had  small  abscesses  forming  round  one  or  two  of  her  finger- 
nails. This  "critical"  symptom — not  at  all  uncommon  in  cases  of  recent 
maniacal  and  melancholic  condition — seemed  to  do  her  general  brain 
condition  good.  She  passed  in  a  month  into  a  quiet,  lethargic,  rather 
suspicious  state,  and  still  depressed,  but  with  no  intense  mental  pain,  and 
no  delusions  expressed.  Then  she  got  into  the  state  that  is  very  common 
before  recovery  in  patients  in  asylums — one  of  discontent,  of  increasing 
instant  desire  to  "go  home,"  inability  to  understand  that  anything  has 
been  wrong,  or  that  further  treatment  away  from  home  is  required.  I 
have  ten  times  the  trouble  with  my  patients — and  sometimes  with  their 
friends — in  this  stage,  for  the  chief  symptoms  of  the  disease  have  passed 
off,  and  the  patients  seem  rational.  She  was  dull  and  suspicious  in  the 
mornings,  and  quite  well  sometimes  in  the  evenings.  All  this  time  she 
was  gaining  in  flesh  and  color  and  strength,  walking  much,  drinking 
much  milk,  and  being  encouraged  to  employ  herself  in  the  house.  In 
three  months  she  was  sent  to  our  sea-side  house,  and  had  sea  air  and  sea 
bathing,  both  of  which  did  her  much  good.  By  that  time  she  had  gained 
a  stone  in  weight.  In  four  months,  she  menstruated  for  the  first  time, 
the  last  cloud  of  depression  passed  away,  and  she  was  sent  home  quite  well. 

The  following  is  a  typical  case  of  puerperal  insanity  dying  of  sep- 
ticaemia, or  a  case,  more  probably,  of  puerperal  fever  with  maniacal 
symptoms : 

K.  G.,  set.  23,  of  a  cheerful  disposition  and  good  habits.  Sister  and 
aunt  have  been  insane.  Has  been  married  between  four  and  five  years, 
and  has  had  four  children  in  that  time,  all  born  dead,  all  the  labors  being 
difiicult  on  account  of  a  deformed  pelvis.  Had  been  weak  during  all  the 
last  pregnancy,  and  had  pains  in  the  head  for  two  months  before  delivery. 
Premature  labor  was  induced  about  the  seventh  month,  with  a  view  of 
saving  the  child  and  making  her  labor  more  easy  than  the  others  had 
been.  In  a  day  or  two  after  delivery  she  began  to  see  faces  on  the  wall, 
to  think  that  the  chairs  -^ere  alive,  and  that  people  were  whispering 
slanders  about  her.  She  did  not  sleep,  and  would  not  take  food.  She 
got  rapidly  worse,  becoming  quite  maniacal,  delirious,  and  unmanageable. 
She  imagined  poison  was  put  into  her  food,  and  wanted  to  rush  away 
from  home.  On  admission  she  exhibited  a  combination  of  intense  ex- 
citement in  paroxysms,  during  which  she  required  three  attendants  to 
hold  her  in  bed,  with  extreme  prostration  and  weakness  between.  Her 
pulse  was  thready  and  156,  temperature  102°,  respirations  60.  There 
was  an  anxious  look,  with  great  pallor  of  countenance,  when  not  excited. 
There  was  evidence  of  congestion  of  both  lungs,  with  pneumonia  at  the 
bases.  There  was  no  evidence  of  tenderness  on  pressure  over  uterus. 
No  lochial  discharge.  She  was  fed  with  brandy  and  custards  on  admis- 
sion, and  every  hour  thereafter,  getting  ten  grains  of  quinine  every  two 


PUERPERAL    INSANITY.  355 

hours  for  the  first  eight  hours.  In  spite  of  all  that  could  be  done  she 
sank  on  the  sixth  day,  the  temperature  having  kept  up  all  the  time  to 
between  101.4°  and  103.8°,  the  lung  symptoms  getting  worse,  and  the 
intense  delirious  excitement  coming  on  once  or  twice  eveiy  day  except 
the  last. 

On  post-mortem  examination  I  found  the  brain  intensely  congested, 
and  the  lungs  pleuritic,  very  congested,  and  almost  hepatized  at  bases. 
But  the  chief  seat  of  disease  was  in  and  round  the  womb.  There  was  a 
thin  layer  of  pus  on  its  peritoneal  surface.  There  was  a  small  abscess  in 
the  right  ovary,  which  seemed  to  occupy  the  position  of  a  recent  corpus 
luteum.  The  uterus  was  large  and  flabby  (about  six  inches  by  three 
inches),  its  substance  on  section  containing  much  purulent  matter  all 
through  it,  but  especially  towards  the  mucous  membrane  in  the  fundus. 
The  mucous  membrane  was  thickened  and  covered  with  yellowish  purulent 
matter,  and  some  of  the  remains  of  the  placenta  were  adherent.  One  of 
the  uterine  veins  on  the  right  side,  for  about  four  inches  in  its  course 
towards  the  vena  cava,  was  unusually  enlarged,  looking  like  a  bit  of 
very  small  intestine,  its  coat  thickened,  and  its  lumen  filled  with  thick 
grumous  pus. 

It  is  difficult  to  say  whether  this  was  a  case  of  "puerperal  insanity" 
with  septicaemia,  or  "puerperal  fever"  with  maniacal  delirium.  I  think 
the  latter  is  the  more  correct  description.  It  was,  I  think,  evident  from 
the  post-mortem  appearances  that  there  was  septicaemic  puerperal  fever 
from  the  beginning,  and  this  occurring  in  a  weakened  anaemic  brain  pre- 
disposed to  insanity  no  doubt  produced  the  maniacal  symptoms. 

I  had  this  year  a  case  of  puerperal  insanity,  K.  H.,  dying  in  four  days 
of  meningitis,  which  came  on  twelve  days  after  the  premature  birth  of  an 
illegitimate  child.  On  admission  to  the  asylum,  two  days  after  the  be- 
ginning of  her  illness,  she  had  a  temperature  of  103.2°,  a  pulse  of  128, 
respirations  56  per  minute,  intense  exhaustion  and  collapse,  muscular 
subsultus  and  constant  moving  about  of  her  hands,  a  low,  muttering  de- 
lirium, with  no  memory,  no  power  of  attention,  and  no  coherence.  She 
gradually  sank  on  the  second  day,  her  temperature  rising  to  104°.  This 
whole  condition  had  arisen  suddenly,  and  developed  at  once  into  great 
intensity.  After  death  there  was  found  inside  the  dura  mater  a  loose 
membrane  containing  numerous  spots  of  hemorrhage,  the  surface  having 
a  yellowish,  sticky  look.  This  extended  all  over  the  base  of  the  brain. 
The  lining  membrane  of  the  fourth  ventricle  was  granular.  On  the 
auriculo-ventricular  valves  of  the  heart  there  were  roughnesses  with 
tough  clots  covering  them.  The  womb  and  its  appendages  were  normal 
for  the  period  after  delivery.  In  a  case  with  such  post-mortem  appear- 
ances I  was  a  little  suspicious  of  syphilitic  infection,  considering  the  pre- 
mature labor  and  the  meningeal  appearances  after  death. 

I  have  gone  carefully  over  the  histories  of  all  the  puerperal  cases  that 
have  been  sent  here  during  the  past  nine  years.  They  were  all  under 
my  own  care,  and  the  histories  were  taken  on  a  uniform  plan  of  my  own 
by  the  assistant  physicians.  There  were  seventy-five  cases  altogether 
counted  as  puerperal,  but  fifteen  of  these  were  either  old  cases  not  sent 
in  for  periods  over  a  year,  or  the  same  cases  admitted  twice  during  the 
same  attack.     These  I  omitted  as  having  no  clinical  value.     The  re- 


356  PUERPERAL    INSANITY. 

maining  sixty,  on  analysis  and  study  of  their  characters  and  clinical 
symptoms  and  results,  form  a  very  instructive  physician's  lesson.  Looking 
at  their  ages,  it  seems  as  if  the  disease  occurred  in  just  about  the  frequency 
that  ordinary  confinements  occur  at  the  same  ages.^  Forty-four  of  the 
cases  had  never  been  insane  before. 

In  addition  to  the  puerperal  state  as  the  great  exciting  cause  of  the 
disease  in  those  sixty  cases,  I  found  that  there  existed  as  a  predisposing 
cause  a  heredity  to  insanity  in  twenty-two  of  the  forty -nine  cases  in 
which  this  point  could  be  ascertained.  No  doubt  heredity  played  a 
much  more  important  part  than  this  if  the  facts  could  have  been  accu- 
rately ascertained,  but  this  is  above  the  average  of  the  ascertained  heredity 
in  our  asylum  tables  for  the  same  nine  years.  Moral  causes  acting  during 
the  puerperal  state  were  common,  such  as  the  deaths  of  children,  desertion 
of  husband,  frights,.etc.  The  incidence  and  importance  of  such  causes  of 
the  disease  are  best  shown  by  the  fact  that  in  thirteen,  or  twenty-five 
per  cent,  of  the  cases,  the  children  had  been  illegitimate.  The  average 
rate  of  illegitimacy  in  Edinburgh  is  about  one-third  of  this.  Severe  post- 
partum hemorrhage,  or  difficult  or  instrumental  labors,  had  occurred  in 
at  least  ten  cases.  But  all  these  causes  leave  a  considerable  proportion 
of  the  cases  where  there  was  no  exciting  cause  at  all,  except  a  normal 
labor  and  its  accompaniments. 

Looking  next  at  the  question  of  which  confinement  the  disease  oc- 
curred most  commonly  after,  I  find  that  twenty  cases,  or  one-third  of  the 
whole,  occurred  after  first  confinements.  This  is  of  course  out  of  all  pro- 
portion to  the  number  of  first  confinements  in  the  population.  The 
remaining  two-thirds  happened,  some  in  each  confinement  up  to  the 
eighth.  This  merely  confirms  what  was  well  known  before,  that  primiparce, 
are  most  subject  to  the  disease.  Then  as  to  the  period  of  occurrence  after 
confinement.  In  eighteen  cases  this  was  not  precisely  ascertained,  but  in 
nearly  all  these  it  was  within  the  first  fortnight.  Of  the  remaining  forty- 
two  cases  the  disease  began  within  the  first  week  in  twenty-one,  and  in 
eleven  more  within  the  second  week,  so  that  we  may  say  that  in  eighty 
per  cent,  of  the  cases  it  began  within  the  first  fortnight.  If  that  period 
is  passed,  it  is  clear  that  the  chief  risk  is  over  in  a  woman  in  childbed 
from  this  disease,  the  first  week  being  by  far  the  most  liable  to  its  inva- 
sion. At  least  half  the  cases  occur  then.  Only  one  case  of  the  sixty 
occurred  after  the  twenty-eighth  day. 

The  next  point  is  very  important  clinically.  Of  the  sixty  cases  no 
less  than  forty-three  were  very  acute  in  character  and  symptoms,  while 
seventeen  only  were  mild  and  without  acute  symptoms.  Twenty-nine  of 
the  forty-three  acute  cases  were  generally  maniacal  in  character,  and 
fourteen  generally  melancholic  with  motor  excitement,  some  of  each  of 
these  classes  changing  from  one  state  to  the  other  at  times.  In  the  mild 
cases  the  prevailing  character  was  mental  depression,  fourteen  of  the 
seventeen  being  so.     In  at  least  eighteen  of  the  acutely  maniacal  cases, 

1  From  15  to  20  years  of  age  in  3  cases. 
"     20  "  25        "        "        16     " 
"      25  "  30        "         "        20    " 
"      30  "  35        "        "  9     " 

"      35  "  40        "        "        12     " 


PUERPERAL    INSANITY. 


357 


the  mania  amounted  to  absolute  delirium,  with  no  power  of  attention  and 
no  coherence  of  speech  whatever.  I  know  of  no  clinical  form  of  insanity 
that  would  yield  so  large  a  proportion  of  very  acute  cases.  Puerperal 
insanity  may  therefore  be  regarded  as  the  most  acute  of  all  forms. 

The  temperature  of  all  cases  on  and  after  admission  was  taken. ^  It  is 
always  a  most  instructive  record  to  look  at  the  column  of  "  highest  tem- 
peratures" in  each  case. 

Of  the  sixty  there  were  thirty-four  cases  under  99°,  and  therefore 
they  cannot  be  said  to  be  above  the  average  temperature  of  ordinary 
health,  or  at  all  events  of  the  average  temperature  of  the  insane.  But 
twenty-six  cases,  or  forty-three  per  cent,  of  the  whole,  were  over  this,  and 
of  these  fourteen  cases,  or  twenty-three  per  cent,  of  the  whole,  were  over 
100°.  No  other  form  of  insanity  shows  this  alarming  result,  for  a  tem- 
perature of  over  100°  I  look  on  with  alarm  in  any  form  of  mental  disease. 
The  most  serious  part  of  it  was,  as  we  shall  see,  that  all  the  deaths  oc- 
curred in  the  cases  with  a  temperature  over  100°.  Yet  to  show  that  a 
high  temperature,  though  alarming,  is  not  necessarily  prognostic  of  death, 
I  find  that  of  the  five  cases  where  it  was  over  103°  three  made  excellent 
recoveries.  I  lately  saw  a  case  in  private  practice  who  recovered,  and 
whose  temperature  had  been  over  105°.  The  causes  of  the  high  tem- 
perature differed  in  different  cases.  The  chief  causes  were — (1)  simple 
acute  brain  excitement ;  (2)  inflammation  of  the  womb  and  surroundings, 
in  some  cases  septic,  in  others  simple ;  (3)  meningeal  inflammation  ;  (4) 
incidental  causes,  such  as  malaria,  mammary  abscess,  etc. 

The  most  common  and  one  of  the  most  important  of  all  the  symptoms 
present  was  the  refusal  of  food — paralysis  of  appetite.  In  thirty  cases, 
or  one-half  of  them,  this  was  present.  It  could  not  be  overcome  but  by 
the  use  of  the  stomach-pump  or  nose-tube  in  about  ten  cases.  In  a 
puerperal  case  refusing  food  I  now  use  forcible  feeding  at  once  if  food 
cannot  be  given  in  any  other  way.  In  no  other  kind  of  mental  disease 
has  the  doctor's  instructions  to  the  nurse  to  be,  "give  much  food  and 
give  it  often."  I  am  quite  sure  that  most  of  the  puerperal  cases  not 
septicemic  that  die  at  home  or  in  asylums  die  from  want  of  early  feeding. 
I  give  stimulants,  too,  in  larger  quantities  with  the  food  than  in  any 
other  kind  of  insanity.  I  have  seen  the  greatest  and  most  evident  good 
results  from  large  doses  of  quinine  as  an  antipyretic.  In  the  case  to 
which  I  have  alluded  where  the  temperature  was  over  105°,  every  ten- 
grain  dose  of  quinine  was  followed  regularly  by  a  fall  of  from  2°  to  4°  of 
temperature. 

There  were  many  other  symptoms,  mental  and  bodily,  very  common 
besides  a  high  temperature.  Tenderness  on  pressure  over  the  region  of 
the  womb  was  common,  and  whenever  it  is  present  I  am  in  the  habit  of 
ordering  warm  water  vaginal  carbolized  injections  and  warm  slightly 
counter-irritating  poultices  over  the  abdomen,  with  sometimes  blistering, 
over  the  pubes.     Local  abscesses  in  the  ankles,  fingers,  wrists,  and  body 


1  From    96°  to    97°  in    3  cases. 
«'       97°  "     98°  "  10    " 
"        98°  "     99°  "  21     " 
"        99°  "  100°  "  12     " 
"      100°  "  101°  "     2     " 


From  101°  to  102°  in  3  cases. 

"      102°  "  103°  "  4     " 

"      103°  "  104°  "  3     " 

"      104°  "  105°  "  1     " 

"      105°  "  106°  "  1     " 


868  PUERPERAL    INSANITY.   ' 

occurred  in  some  cases.  Muscular  jactitation  and  subsultus  occurred  in 
some  of  the  worst  cases,  but  was  not  always  followed  by  collapse.  (Edema 
and  albuminuria  were  present  in  two  cases,  and  convulsions  in  one.  Of 
the  mental  symptoms,  one  of  the  most  important  from  its  great  frequency 
was  the  suicidal  impulse.  It  was  present  in  twenty-five  cases,  or  forty 
per  cent,  of  the  whole.  It  was  present  in  an  impulsive  form  in  many  of 
the  maniacal  as  well  as  some  of  the  melancholic  cases.  No  medical  man, 
therefore,  in  treating  a  case  of  puerperal  insanity,  but  should  keep  in 
mind  that  the  patient  may  attempt  suicide,  and  he  should  warn  the  nurses 
and  attendants  of  this. 

The  presence  of  hallucinations  of  the  senses,  especially  of  hearing,  I 
was  surprised  to  find  so  common.  They  occurred  in  at  least  one-third  of 
the  cases,  and  were  very  often  persistent,  as  hallucinations  of  hearing  are 
apt  to  be,  after  the  other  symptoms  were  passing  ofi".  But  they  did  not 
indicate  incurability,  as  is  the  case  so  often  in  chronic  auditory  halluci- 
nations of  alcoholic  origin. 

The  patients  in  many  cases  passed  from  the  acute  stage  into  one  of 
stupor,  and  in  some  this  existed  from  the  beginning.  At  one  part  or 
other  of  the  case  stupor  was  present  in  at  least  fifteen  cases,  or  twenty- 
five  per  cent.  It  was  connected,  I  fear,  in  some  of  them  with  the  habit 
of  masturbation,  to  which  puerperal  cases  are  very  subject.  Neither  the 
stupor  nor  the  masturbation  indicates  incurability.  One  case  in  which 
both  were  the  most  prominent  symptoms  recovered. 

The  last  and  most  important  point  brought  out  in  this  study  of  these 
sixty  puerperal  mental  cases  is  the  great  curability  of  the  disease.  Thirty- 
three  cases  were  discharged  recovered,  and  seventeen  were  discharged 
much  improved.  Of  the  latter  the  prospects  of  complete  recovery  were 
very  good.  I  actually  know  they  did  complete  their  recovery  in  twelve 
cases.  That  is,  forty-five  cases  out  of  the  sixty  recovered,  which  amounts 
to  a  recovery  rate  of  seventy-five  per  cent.  Most  of  the  recoveries  took 
place  quickly.  In  three  months  from  the  beginning  of  the  attack  over 
one-half  of  the  cases  were  well,  and  in  six  months  ninety  per  cent,  of 
those  who  recovered  were  well.  But  to  prevent  anything  like  loss  of 
hope,  I  mention  that  one  of  the  melancholic  cases  with  stupor  recovered 
after  the  disease  had  existed  for  four  years.  No  recoveries  from  mental 
disease  are  generally  better  or  more  satisfactory  than  those  from  puerperal 
insanity.  In  some  cases  recovery  was  very  rapid  indeed  after  it  began. 
In  the  cases  where  stupor  existed  or  supervened  on  acute  insanity,  the 
occurrence  of  menstruation  seemed  often  to  act  as  the  exciting  cause  of 
recovery.  I  myself  believe  that  this  was  mostly  a  coincidence,  or  rather 
I  should  put  it  that  sanity  was  the  mental,  and  menstruation  the  chief 
bodily  symptom  of  the  restoration  of  brain  and  body  to  their  normal 
working.  It  is  the  proper  mode  of  treatment,  however,  whenever  a 
puerperal  case  gets  strong  in  body  and  the  body  weight  becomes  normal, 
to  use  every  means  to  restore  menstruation  if  it  has  not  returned.  Warm 
baths  at  night,  mild  shower-baths  in  the  morning,  hip  baths  with  mustard, 
aloes,  and  iron  pills,  and  borax  at  the  time  menstruation  is  expected,  are 
all  useful  in  addition  to  the  general  tonic  and  fresh  air  treatment.  Men- 
struation returning  before  the  general  strength  is  improved  is  usually  a 


LACTATIONAL    INSANITY.  359 

bad  thing,  for  it  is  apt  to  be  attended  with  increased  mental  excitement, 
and  is  apt  to  become  menorrhagic. 

Looking  at  curability  of  the  cases  according  to  their  characters  of 
acuteness  or  mildness,  and  of  mental  exaltation  or  depression,  I  find  that 
the  forty-three  acute  cases  recovered  in  the  proportion  of  eighty-one  per 
cent.,  and  the  seventeen  mild  cases  in  the  proportion  of  only  sixty- two 
per  cent.  But  then  it  must  be  kept  in  mind  that  the  mild  cases  were 
longer  in  being  sent  into  the  asylum,  and  of  the  total  number  of  mild 
puerperal  cases  occurring,  the  most  intractable  and  prolonged  would  be 
the  only  ones  sent  into  the  asylum,  the  rest  would  recover  at  home.  Of 
the  exalted  and  depressed  cases  (mania  and  melancholia),  an  almost  equal 
proportion,  that  is  seventy -five  per  cent.,  of  each  recovered. 

Five  of  the  sixty  cases  died,  four  of  them  within  a  month  of  the  onset 
of  the  disease,  and  one  within  two  months.  This  is  a  mortality  of  8.3 
per  cent,  of  the  cases.  No  cases  are  more  difiicult  to  get  post-mortem 
examinations  in  than  puerperal  cases,  and  they  were  performed  in  only 
three  of  the  five  cases.  The  cause  of  death  in  one  was  found  to  be  phthisis 
pulmonalis,  under  which  the  patient  had  labored  for  long  before  her  con- 
finement, and  which  as  usual  advanced  rapidly  after  parturition ;  in 
another  it  was  septicaemia ;  and  in  the  third  simple  maniacal  exhaustion, 
without  symptoms  of  septicaemia.  There  is  no  doubt,  however,  that  the 
chief  cause  of  death  in  puerperal  cases  that  have  been  properly  fed  is 
septicaemia.  They  are,  in  fiict,  cases  of  combined  puerperal  fever  and 
puerperal  mania,  the  mania  having  more  of  the  character  of  delirium 
than  of  ordinary  insanity.  It  is  curious  that  there  was  no  history  of 
preliminary  chill  in  the  septicsemic  cases.  As  I  said,  I  do  not  like  the 
temperature  to  run  up  much  above  100°  in  puerperal  cases.  Of  the 
fourteen  cases  in  which  this  took  place  five  died,  or  thirty-five  per  cent. 
I  still  less  like  to  see  muscular  subsultus  with  a  restless  moving  of  the 
hands  and  twitching  of  the  facial  muscles.  There  may  be  septicaemia  in 
a  puerperal  case  with  purulent  peritonitis,  metritis,  and  phlebitis,  and  yet 
the  patient  never  complain  of  any  local  pain,  and  even  on  pressure  there 
may  be  no  uterine  or  peritoneal  tenderness.^  Many  of  the  cases  with  the 
worst  symptoms,  bodily  and  mental,  made  good  recoveries. 


LACTATIONAL   INSANITY. 

Nursing  in  women  is  the  cause  of  mental  disease  sometimes.  The 
poor  are  more  liable  to  this  than  the  rich,  both  being  equally  subject  to 
puerperal  insanity.  This  is  as  might  be  expected.  If  the  wife  of  a 
laborer  has  had  ten  children  and  nursed  them  all,  if  she  has,  during 
all  the  years  those  ten  pregnancies  and  childbirths  and  nursings  have 
been  going  on,  had  to  work  hard,  if  she  has  had  to  struggle  with  poverty 
and  insufficient  necessaries  of  life  in  addition  to  this  continuous  repro- 
ductive struggle  and  family  worries,  if  in  addition  to  all  this  she  has  in- 
herited a  tendency  to  mental  disease,  no  physiologist  or  physician  can 

*  These  statistics  may  be  carefully  compared  and  supplemented  by  Dr.  J.  Batty 
Tuke's  statistics,  obtained  from  an  analysis  of  cases  in  this  asylum,  in  the  Edinburgh 
Medical  Journal  for  May,  1865. 


860  LACTATIONAL    INSANITY. 

wonder  if  she  should  become  insane  during  the  tenth  nursing.  Indeed, 
the  wonder  is  that  any  organism  could  possibly  have  survived  in  body  or 
brain  such  a  terrible  strain  and  output  of  energy  in  all  directions.  Such 
a  woman  often  enough  becomes  insane  during  a  nursing  long  before  the 
tenth.  An  organic  sense  of  duty  and  a  stern  physiological  necessity 
among  poor  women  compel  them  to  nurse  their  offspring.  What  else 
can  they  do  ?  It  is  well  for  the  offspring,  but  the  mother  often  enough 
dies,  or  is  upset  in  body  or  brain  in  the  attempt. 

A  typical  case  of  lactational  insanity  is  one  occurring  in  the  case  of  a 
poor  woman  who  has  had  several  children,  and  has  nursed  the  last  for 
several  months,  who  has  got  pale  and  thin  in  the  process,  and  become 
subject  to  headaches,  noises  in  her  ears,  giddiness,  flashes  of  light  before 
her  eyes,  lassitude  and  nervous  irritability,  in  fact  to  the  usual  symptoms 
of  general  bloodlessness  and  brain  anaemia.  She  then  gets  depressed  in 
mind,  her  sleep  leaves  her,  her  self-control  is  lost,  and  she  becomes  either 
lethargic  and  stupid  or  suicidal,  with  delusions  that  her  husband  and 
neighbors  are  against  her,  thereby,  poor  woman,  merely  misinterpreting 
her  sensations  of  mental  pain  and  distress.  She  had  little  organic  strength 
for  her  pregnancy,  still  less  for  her  delivery,  and  it  has  quite  broken  down 
in  her  nursing.  To  such  a  woman  the  organic  delight  of  suckling  her 
infant,  for  which  the  maternal  nature  craves  and  is  satisfied  by  the 
process,  becomes  an  irritation,  an  excitement,  and  an  exhaustion.  But 
such  a  typical  case,  if  taken  in  time,  and  if  nursing  is  stopped  and  rest 
is  given,  with  good,  nourishing  food,  malt  liquors,  and  iron  and  cod-liver 
oil,  and  fresh  air,  at  once  begins  to  amend,  sleeps,  acquires  self-control, 
ceases  to  imagine  things  that  have  no  objective  existence,  puts  on  flesh, 
begins  to  employ  herself,  gets  cheerfiil,  and  is  quite  well  and  strong  in 
three  months,  her  blood  containing  many  more  blood  corpuscles  than  it 
had  when  treatment  was  begun,  and  the  renourished  brain  resuming  all 
its  normal  functions  in  a  normal  way.  But  cases  of  lactational  insanity 
vary  greatly  in  form,  degree  of  mental  disturbance,  and  duration  of  attack. 
It  must  be  admitted  that  they  do  not  follow  one  type.  They  are  nearly 
all  melancholic  at  some  period  of  the  attack.  They  nearly  all  suffer  from 
premonitory  neuroses  of  sensation  in  the  shape  of  headaches,  lassitude, 
neuralgia,  feelings  of  sinking  at  pit  of  stomach,  or  some  of  the  other 
signs  of  anaemia  and  ill-nourishment.  They  are  all  very  curable  if  put 
under  proper  treatment  in  proper  time. 

The  following  case  is  an  almost  typical  one,  except  that  the  first  part 
of  the  asylum  stage  of  it  was  more  acute  than  usual :  K.  J.,  aet.  40,  the 
wife  of  a  plumber,  who  earned  when  in  full  work  twenty-eight  shillings 
a  week,  has  had  seven  children  in  sixteen  years,  and  nursed  each  about 
fifteen  months.  There  is  no  known  heredity  to  insanity.  She  nursed 
the  last  child  for  twelve  months,  and  of  course  had  to  do  her  family 
duties  meanwhile.  Her  first  symptoms  were  great  depression  and  want 
of  energy.  She  would  sit  for  hours  doing  nothing,  saying  nothing,  and 
taking  no  notice  of  anything.  Her  brain  seemed  to  have  been  exhausted 
in  its  power  to  energize  mentally.  Then  she  began  to  be  restless  and 
sleepless,  and  her  head  felt  sore  and  queer.  Soon  she  became  delusional 
— fancying  she  saw  friends  in  the  street  who  were  in  the  colonies.  She 
was  sent  at  first  to  the  Royal  Infirmary  here,  but  proving  unmanageable 


LACTATIONAL    INSANITY.  361 

there,  she  was  at  last  sent  here.  On  admission  she  was  markedly  de- 
pressed, and  the  mental  working  of  her  brain  was  enfeebled  in  such  a 
way  that  she  would  begin  a  sentence  in  answer  to  a  question,  and  would 
stop  in  the  middle,  her  volitional  power  having  run  short  apparently. 
She  rambled  in  speech  and  mistook  the  identity  of  persons  round  her. 
She  had  the  delusion  that  she  was  to  be  burned  at  the  stake.  She  was 
thin,  pale,  muscularly  feeble,  lacking  in  energy,  with  blunted  sensibility. 
Her  special  senses  were  blunted,  pulse  small  and  weak,  temperature  98,8°. 
After  admission  she  was  sleepless,  restless,  and  acutely  excited  for  a  week. 
Then  she  became  more  quiet,  with  short  intervals  of  almost  sanity,  but 
with  impulsive  action.  Sitting  quietly  sewing  in  a  room  with  others, 
she  would  suddenly  drop  on  her  knees  and  pray  aloud.  Was  put  on 
extra  diet,  with  porter  and  quinine  and  iron.  She  always  got  worse  and 
more  delusional  in  the  evening,  this  fact  probably  indicating  that  by  that 
time  her  brain  power  was  getting  exhausted.  But  she  steadily  picked  up 
in  flesh  and  strength,  mental  and  bodily,  and  in  ten  months  was  discharged 
almost  recovered,  having  gained  twenty-four  pounds  in  weight,  and  looking 
fresh  and  healthy.  What  will  happen  if  she  has  more  children,  and  nurses 
each  of  them  fifteen  months,  can  easily  be  conjectured. 

The  treatment  of  lactational  insanity  is  simple  and  physiological.  Stop 
the  nursing,  give  nourishment  in  abundance  with  some  malt  liquor,  change 
the  scene,  free  the  patient  from  family  cares  for  a  time,  give  quinine,  iron, 
cod-liver  oil,  and  tonics  generally.  The  suicidal  tendency  must  be  thought 
of  and  guarded  against  if  present,  as  it  is  in  a  very  large  proportion  of  the 
cases. 

A  survey  of  my  nine  years'  clinical  experience  in  the  Royal  Edinburgh 
Asylum,  1874—1882,  in  regard  to  lactational  insanity  is  instructive.  We 
have  had  altogether  fifty-two  cases  that  I  classified  as  lactational.  But 
some  of  these  were  old  cases  of  the  disease  transferred  from  other  asylums, 
or  readmitted,  and  those  I  shall  take  no  notice  of.  Their  study  would 
lead  to  no  good  clinical  results,  and  would  merely  tend  to  confusion. 
Forty  of  the  cases  were  admitted  laboring  under  recent  lactational  in- 
sanity, and  of  these  only  I  shall  speak.  As  classified  on  admission, 
twenty -one  of  these  were  cases  of  mania  and  nineteen  of  them  of  melan- 
cholia. Only  about  half  of  these  twenty-one  cases  of  mania  had  mental 
exaltation  as  their  predominant  feature  throughout  their  whole  course, 
the  others  beginning  with  marked  melancholic  symptoms  or  ending  with 
them.  But  the  fact  that  half  the  cases  were  maniacal  during  their  most 
acute,  period  shows  that  the  insanity  of  lactation  is  by  no  means  exclu- 
sively a  melancholic  form  of  mental  disease.  It  shows  that  bodily  and 
nervous  exhaustion  and  malnutrition,  though  their  first  mental  symptoms 
may  be  mental  depression,  yet  tend  in  a  large  number  of  cases  towards 
morbid  mental  exaltation  in  the  long  run,  mania  being  in  fact  another 
and  a  further  stage  of  the  convolutional  brain  disturbance.  When 
classified  according  to  the  acuteness  or  mildness  of  their  symptoms,  in- 
dependently of  psychical  exaltation  or  depi'ession,  I  find  there  Avere  twenty- 
two  acute  cases  and  eighteen  mild  ones,  the  majority  (eighteen)  of  the 
acute  cases  being  maniacal,  and  a  majority  (thirteen)  of  the  mild  cases 
being  melancholic. 

As  regards  the  months  of  nursing  in  which  the  disease  occurred,  my 


362 


LACTATIONAL    INSANITY. 


records  do  not  state  this  point  in  seventeen,  but  of  the  remaining  no  less 
than  ten  occurred  within  the  first  three  months,  seven  in  the  next  three, 
four  in  the  next  three,  and  only  two  in  the  last  three  months.  I  confess 
I  was  surprised  at  this.  It  is  a  different  result  from  that  arrived  at  by 
Dr.  Batty  Tuke  from  an  examination  into  the  statistics  of  fifty-four  cases 
of  the  insanity  of  lactation  that  had  been  in  this  asylum  previous  to  May, 
1865.  Only  two  of  his  cases  occurred  within  the  third  month,  and  only 
eight  within  the  first  six  months  of  nursing,  while  twenty-one  cases,  or 
fifty-one  per  cent,  of  those  in  whom  the  period  was  recorded,  occurred 
after  the  ninth  month  of  nursing,  my  percentage  for  the  same  period 
being  nine.  Such  a  diversity  of  results  is  enough  to  make  one  despair  of 
the  value  of  looking  at  clinical  facts  in  a  statistical  form.  My  statistics 
distinctly  point  to  the  causation  of  this  form  of  mental  disease  being  largely 
due  to  the  disturbance  of  the  puerperal  period  aggravated  by  the  reflex 
excitation  of  the  brain  through  the  physiological  act  of  suckling  the 
infants.  Dr.  Tuke's  statistics  clearly  point  to  a  preponderating  causation 
by  the  exhaustion  of  mere  long-continued  nursing.  Both  causes  operate, 
I  have  no  doubt,  but  why  they  should  have  operated  so  differently  in  the 
cases  in  the  same  asylum  at  different  periods  I  am  unable  to  explain. 
My  records  were  so  deficient  in  regard  to  which  nursing  the  disease  oc- 
curred in  as  to  be  worthless.  They  merely  show  that  lactational  insanity 
may  occur  after  the  first  child  or  the  seventh.  The  suicidal  impulse  is 
common,  seventeen  of  the  forty  having  had  it  in  greater  or  less  intensity. 
The  temperature  shows  a  very  marked  difference  from  the  puerperal  form 
of  insanity.^  A  glance  at  the  highest  temperature  shows  that  only  about 
one-third  of  the  cases  (thirteen)  were  over  the  normal  standard,  and  of 
these,  the  great  majority  (eight)  were  only  between  99°  and  100°.  Three 
were  between  100°  and  101°,  leaving  only  two  that  were  over  that,  in  one 
of  whom  it  was  caused  by  an  inflamed  breast.  The  temperature  record 
shows  clearly  the  milder  type  of  lactational  insanity  as  compared  with 
the  puerperal  form.  The  thermometer,  though  the  readings  seldom 
reach  very  high  in  uncomplicated  mental  disease,  I  look  on  as  being 
simply  invaluable  as  showing  the  intensity  of  the  brain  action.  Its 
readings  upwards,  from  normal  to  102°  or  103°,  are  usually  in  an  exact 
ratio  to  the  intensity  of  the  mental  disease.  Only,  it  must  be  re- 
membered, that  half  a  degree  in  the  estimation  of  the  intensity  of  brain 
overaction  is  equivalent  to  two  degrees  in  the  measurement  of  febrile 
disturbance.  I  attach  especial  importance  to  the  readings  of  the  ther- 
mometer in  all  acute  mental  diseases,  and  have  used  it  in  every  case 
under  my  care  in  the  Carlisle  and  Royal  Edinburgh  Asylums  for  the  past 
sixteen  years. 

Heredity  to  insanity  was  known  to  be  present  in  fifteen  of  the  cases  ; 
but  then  in  twelve  of  the  forty  no  reliable  information  on  this  point  could 
be  got.  And  as  proximate  causes,  mental  and  moral  disturbances  oc- 
curred in  nine  of  the  cases. 

Let  us  look  now  at  the  results  of  treatment,  that  most  interesting  of 


»  From  96°  to    97°  in    1  case. 
"      97°  "     98°  "     6     " 
"      98°  "     99°  "  20     " 
"     99°  "  100°  "     8     " 


Trom  100°  to  101°  in  3  cases. 
"     101°  "  102°  "  0     " 
"     102°  "  103°  "  1     " 
"     103°  "  104°  "  1     " 


THE    INSANITY    OF    PREGNANCY.  363 

all  questions  to  the  physician,  and  still  more  so  to  the  relatives  of  the 
patients.  Thirty-one  of  the  forty  cases  recovered,  and  three  more  were 
removed  from  the  asylum  uncured  but  improving.  This  is  seventy-seven 
and  a  half  per  cent,  of  actual  recoveries,  and  a  still  higher  figure  of  po- 
tential restorations  to  mental  health.  The  lactational  cases  recovered  in 
slightly  larger  numbers,  therefore,  than  the  puerperal  cases,  and  only 
one  case  of  the  forty  died.  I  find  that  the  maniacal  and  the  melancholic, 
the  acute  and  the  mild  cases  recovered  in  somewhat  equal  proportions.^ 
The  six  who  did  not  get  better,  but  are  still  under  treatment,  were  three 
of  those  patients  who  had  repeated  attacks  of  insanity  before,  the  other 
three  looking  phthisical.  The  lactational  cases  did  not  recover  as  soon 
as  the  puerperal.^  Only  sixteen  recovered  within  three  months,  but 
twenty-five,  or  sixty-two  per  cent,  of  all  the  cases,  and  eighty  per  cent, 
of  the  recoveries,  recovered  within  six  months,  and  all  of  them  within 
eighteen  months.  And  they  made  good  and  lasting  recoveries,  few  of 
them  relapsing.  Recovery  in  all  the  patients  was  accompanied  by  a 
great  increase  in  body  weight,  in  strength,  in  appetite,  and  in  fatness. 
In  some  menstruation  continued  during  the  disease,  and  in  its  earlier 
stages  acted  as  an  excitant  and  exhauster  of  strength.  It  was  often 
menorrhagic  in  such  cases.  The  function  when  absent  usually  returned 
of  itself  without  any  special  treatment  as  the  nutrition  improved. 

One  instructive  fact  I  came  across  in  relation  to  this  disease.  Out  of 
one  hundred  and  sixty-six  admissions  of  ladies  to  our  higher  class  de- 
partments there  were  only  two  lactational  cases,  while  there  were  among 
them  the  usual  proportion  of  puerperal  cases.  Out  of  1383  pauper  and 
poorer  private  female  patients,  there  were  thirty-eight  lactational  cases. 
In  short,  the  puerperal  cases  were  sent  for  hospital  treatment  in  as  great 
a  proportion  among  the  rich  as  the  poor,  while  the  lactational  cases  were 
only  sent  in  half  that  proportion.  This  points  clearly  to  the  greater 
mildness  of  type  of  the  latter,  and  the  possibility  of  treating  it  at  home, 
if  not  to  the  greater  infrequency  of  the  disease  among  the  well-fed  classes, 
who  have  nurses  to  attend  their  children  and  doctors  to  tell  them  when 
to  stop  nursing  in  time.  Probably  the  custom  among  the  poor  of  nursing 
each  child  a  long  time  in  order  to  delay  the  conception  of  the  next  has 
something  to  do  with  the  greater  prevalence  of  this  form  of  mental  disease 
among  them. 

THE   INSANITY    OF   PREGNANCY. 

Few  women  carry  a  child  without  being  influenced  mentally  thereby 
in  some  way  or  other.  The  psychology  of  pregnancy  has  yet  to  be 
written  in  a  scientific  way.     There  are  innumerable  facts  on  record,  but 

'  Of  the  twenty-one  cases  of  mania  fifteen  recovered  ;  of  the  nineteen  cases  of  melan- 
cholia sixteen  recovered  ;  of  the  twenty-two  acute  cases  fifteen  recovered ;  and  of  the 
eighteen  mild  cases  sixteen  recovered. 

*  Within  1  month  6  cases  recovered.       i       Within    7  months  1  case  recovered. 
II       2       "       6  " 


3  "  4 

4  "  2 

5  "  6 

6  "  1 


8  "  1 

9  "  2 
11  "  1 
18  "  1 


364  THE    INSANITY    OF    PREGNANCY, 

they  are  scattered  and  undigested.  Without  going  into  the  domain  of 
mental  disease  in  any  technical  sense,  we  find  examples  of  partial  mental 
exaltation,  mental  depression,  mental  enfeeblement,  mental  paralysis, 
and  mental  perversion.  No  doubt  the  alterations  are  chiefly  in  the 
affective  faculties,  but  the  reasoning  power,  the  moral  sense,  the  voli- 
tional power,  the  imagination,  and  even  the  memory,  are  often  enough 
affected  in  pregnant  women.  As  a  part  of  the  nervous  disturbance  the 
bodily  appetites  become  changed,  the  physiological  functions  altered,  and 
the  nutrition  of  organs  profoundly  affected.  In  this  state  many  women 
have  endless  caprices,  unfounded  dislikes  and  likings,  cravings  for  foods 
and  drinks  never  before  desired,  unnatural  desires  for  indigestible  things, 
causeless  weeping  and  laughing,  stealing  and  lying,  morbid  thirst  and 
hunger,  an  activity  of  digestion  never  before  known,  pigmentation  of  the 
skin,  alteration  of  the  expression  of  the  face,  of  the  tones  of  the  voice, 
and  of  the  power  of  muscular  coordination.  It  is  scarcely  surprising 
that  every  function  of  the  great  central  nervous  system  should  be  thus 
affected  in  many  cases,  for,  physiologically,  pregnancy  means  a  dynamical 
change  for  the  time  being  in  the  direction  of  some  of  the  great  currents 
of  energy,  and  a  change,  amongst  others,  in  the  quality  of  the  blood. 
Psychologically  it  is  the  fulfilling  of  the  second  strongest  organic  necessity 
of  life,  to  reproduce  the  species.  All  the  changes,  mental  and  bodily,  that 
I  have  referred  to,  and  far  more  than  these,  should  be  taken  into  account 
in  studying  the  question  of  how  pregnancy  produces  those  great  psychical 
disturbances  that  we  call  insanity  in  brains  predisposed  thereto.  A  vast 
number  of  women  are  mentally  unsound  during  pregnancy,  if  judged  by 
an  ideal  standand  of  volitional  power,  while  very  few  indeed  pass  the 
conventional  line  that  divides  sanity  from  insanity.  Nature  seems  to 
care  for  pregnant  women  physiologically  in  all  directions,  and  does  so  in 
the  case  of  the  mental  functions  of  the  brain  convolutions.  Those  may 
be,  and  are  often,  affected  in  pregnancy,  but  are  seldom  quite  upset.  It 
is  a  very  rare  form  as  an  insanity,  as  we  shall  see  from  the  statistics. 
In  fact,  there  is  no  period  in  the  life  of  a  woman  after  the  age  of  twenty- 
five  when  she  is  less  liable  to  actual  insanity  than  during  her  pregnancies. 
But  there  is  a  type  of  case  exactly  the  contrary  of  this  rule,  where  a 
woman  cannot  become  pregnant  without  becoming  insane.  I  have  such 
a  patient  now,  who  has  been  five  times  pregnant  and  five  times  insane, 
each  time  during  pregnancy.  This  no  doubt  is  the  clearest  indication 
nature  could  give  that  such  a  person  should  never  become  pregnant.  I 
had  one  patient,  K.  L.,  who  had  six  different  attacks  of  insanity — two 
of  pregnancy,  two  of  puerperal,  and  two  of  lactation — and  she  made 
perfect  recoveries  from  them  all,  though  in  each  she  was  most  deter- 
minedly suicidal  and  homicidal,  strangling  and  killing  her  first  child, 
and  attempting  at  least  six  different  times  to  take  away  her  own  life. 
Yet  for  the  last  seven  years  she  has  kept  quite  well,  and  done  her  work 
at  home.  She  had  one  or  two  other  children  without  being  affected  in 
mind  more  than  by  a  little  depression. 

The  typical  mental  disturbance  of  pregnancy  of  the  mild  kind  not  re- 
quiring asylum  treatment,  and  often  not  incapacitating  a  woman  from 
doing  her  duties,  consists  of  a  mental  depression,  or  mental  apathy  not 
amounting  to  stupor,  with  a  loss  of  interest  in  things,  a  loss  of  conscious 


THE    INSANITY    OF    PREGNANCY.  365 

affection  for  husband  and  sometimes  for  children,  a  slight  weariness  of 
life,  a  fear  of  something  going  to  happen,  and  a  general  loss  of  courage 
and  a  disinclination  for  social  intercourse.  These  symptoms  do  not 
usually  come  before  the  third  month  of  pregnancy,  and  much  more  fre- 
quently they  do  not  come  on  till  after  the  sixth  month.  Sometimes  they 
only  last  for  a  part  of  the  period  of  pregnancy  and  then  pass  off.  More 
usually  they  do  not  disappear  till  after  delivery.  They  either  do  so  then 
or  become  aggravated  into  a  more  acute  puerperal  psychosis.  There  is 
another  distinct  type  of  case  where  during  the  first  pregnancy  insanity 
comes  on,  becomes  acute,  and  ends  in  dementia  soon.  This  is  no  doubt 
one  of  nature's  ways  of  ending  a  bad  stock  ;  just  as  I  look  on  the  in- 
sanity of  adolescence  to  be,  and  on  sterility  to  be  in  some  cases,  and  on 
sexual  antipathy  to  be,  and  on  absence  of  the  social  instincts.  There  are 
psychological  bachelors  and  old  maids,  born  so,  whom  no  social  cultiva- 
tion or  opportunity  can  make  otherwise,  and  these  will  be  found  to  occur 
usually  in  families  with  a  heredity  to  insanity. 

This  case  presents  the  most  common  type  that  family  doctors  have  to 
do  with  :  K.  M.,  a  married  woman,  vet.  34,  with  an  insane  heredity, 
who  had  borne  five  children  comfortably,  came  to  me  saying  she  was  dull 
and  miserable,  and  could  not  do  her  work  nor  take  an  interest  in  any- 
thing. It  seemed  as  if  she  did  not  care  for  her  husband,  nor  to  do  her 
household  duties,  and  she  said  she  was  afraid  of  hei-self,  meaning  that  she 
might  commit  suicide.  She  was  stout,  strong,  and  well-nourished,  and 
looked  the  picture  of  good  health.  She  slept  well,  ate  well,  and  all  her 
bodily  functions  were  noi-mal.  She  was  in  the  sixth  month  of  pregnancy, 
and  the  mental  change  had  come  on  a  month  before.  I  advised  that  she 
should  have  a  female  friend  with  her,  and  should  go  on  doing  her  work, 
should  walk  much  in  the  fresh  air,  and  wait  patiently  for  her  confine- 
ment. After  the  eighth  month  she  felt  much  better,  and  after  confine- 
ment every  trace  of  her  mental  depression  left  her. 

The  following  was  a  very  acute  case  of  the  insanity  of  pregnancy : 
K.  N.,  aet.  32,  pregnant  of  an  illegitimate  child,  became  at  the  sixth 
month  dull  and  apathetic,  then  within  a  month  incoherent,  talkative,  and 
almost  delirious.  She  would  moan  at  times  as  if  in  pain ;  would  say, 
poor  soul,  "I  am  in  a  fearful  state  ;  never  was  in  such  a  state  as  this." 
She  had  hallucinations  of  sight,  seeing  elephants  all  of  a  green  color 
before  her.  She  was  very  weak  on  admission,  could  not  walk  well  with- 
out assistance,  her  tongue  and  mouth  tended  to  be  dry,  she  had  pain  in 
her  abdomen,  her  ankles  were  swollen,  her  pulse  was  136  and  weak,  and 
her  temperature  100.4°.  She  continued  restless,  depressed,  excited,  and 
sleepless,  and  eight  days  after  admission  was  delivered  of  a  healthy  male 
child.  Her  mental  state  improved  much  thereafter  for  a  week,  when  she 
had  a  relapse.  In  fact,  the  puerperal  state  caused  an  access  of  puerperal 
insanity,  but  in  four  weeks  after  the  birth  of  the  child  the  excitement 
had  passed  off,  the  delusions  only  remaining.  In  another  week  the  de- 
lusions, too,  had  left  her,  and  in  two  months  she  was  discharged  strong 
in  body  and  well  in  mind. 

The  next  is  a  more  characteristic  case,  K.  0.,  set.  30,  a  married 
woman  with  a  hereditary  history  of  insanity,  and  pregnant  with  her  first 
child,  became  insane  six  weeks  before  its  birth ;  a  fear  came  over  her 


366  THE    INSANITY    OF    PKEGNANCY. 

first,  and  she  said,  "I  must  die,  I  must  die."  An  inflammation  in  one 
lung  had  reduced  her  strength,  and  she  had  been  sleepless  for  two  weeks, 
soporifics  having  no  effect.  She  was  suicidal,  and  tried  to  jump  out  of  a 
window.  Her  friends  properly  kept  her  at  home,  nursing  and  looking 
after  her  as  best  they  could  till  the  child  was  born.  She  then  got  much 
worse  mentally,  and  remained  maniacal  for  two  months.  Then  she 
became  apathetic,  confused,  and  childish,  with  occasional  impulsive 
spurts  of  maniacal  excitement.  This  state  lasted  for  a  month,  then  she 
began  to  improve,  and  was  well  in  six  weeks,  her  attack  having  lasted 
altogether  five  months.  The  bromides  and  iron  were  used  largely  in  the 
acute  stage  of  her  disease.  Strychnine  in  the  apathetic  stage,  and  extra 
food  and  fresh  air  and  good  nursing  throughout. 

The  cases  of  the  insanity  of  pregnancy  of  such  an  acute  type  as  to  need 
asylum  treatment  are  rare  and  by  no  means  of  a  uniform  type.  I  have 
had  only  fifteen  such  in  the  past  nine  years  sent  to  the  Royal  Edinburgh 
Asylum  ;  nine  of  these  were  maniacal  and  six  melancholic  ;  nine  of  an 
acute  type,  and  six  were  mild  in  their  symptoms  ;  seven  of  them  were 
suicidal,  some  being  desperately  so.  This  is  an  enormous  proportion  of 
suicidal  cases  for  any  kind  of  insanity.  In  half  of  those  with  a  history 
there  was  heredity  to  insanity,  mostly  strong  and  direct  heredity. 

Of  the  fifteen  cases  only  nine  recovered,  or  sixty  per  cent,  of  the 
whole,  this  form  of  mental  disease  in  its  worse  forms  being  thus  more 
incurable  than  the  insanities  of  childbed  or  nursing.  The  time  of  re- 
covery in  relationship  to  confinement  was  various.  In  only  two  cases  of 
the  nine  who  recovered  was  the  termination  of  pregnancy  attended  with 
speedy  and  marked  mental  recovery.  In  four  cases  confinement  dis- 
tinctly aggravated  the  previously  existing  mental  disease.  In  three  of 
these,  in  fact,  the  symptoms  had  not  been  so  bad  before  confinement  as 
to  need  asylum  treatment  at  all.  The  puerperal  state  seemed  to  bring 
the  insanity  of  pregnancy  to  a  climax  in  those  cases.  In  three  cases  of 
the  nine  who  recovered  they  got  better,  and  were  discharged  from  the 
asylum  recovered  before  they  were  confined.  The  whole  nine  had  re- 
covered in  six  months.  Three  cases  were  transferred  to  other  asylums 
within  four  months  after  admission  here  in  an  improved  condition,  and 
of  these  one  might  possibly  have  got  better  ultimately,  and  one  was  taken 
home  before  recovery  and  did  get  quite  well.  This  would  bring  up  the 
recovery  rate  to  seventy-three  per  cent.  Two  died,  one  of  ureemic 
poisoning  (this  probably  having  been  the  real  cause  of  her  insanity)  in 
seven  days  after  admission,  and  another  of  general  tuberculosis  in  ten 
months. 

Women  are  more  liable  to  become  insane  during  the  first  than  subse- 
quent pregnancies  ;  for  seven  of  the  fifteen  cases  were  first  pregnancies  ; 
and  the  fact  that  five  of  the  fifteen  were  illegitimate  children,  shows  that 
moral  causes  largely  bring  on  the  disease. 

The  coming  on  of  the  disease  was  gradual  in  most  of  the  cases,  and  it 
began  in  all  but  two  with  depression  of  mind  or  apathy  and  stupor. 
The  affection  towards  their  husbands  became  perverted  in  nearly  all  the 
married  cases.  The  psychology  of  the  affection  between  husband  and 
wife,  and  the  way  it  is  influenced  by  sexual  intercourse,  by  pregnancies, 
by  the  children  or  the  absence  of  children,  by  neurotic  constitution  of 


THE    INSANITY    OF    PREGNANCY.  367 

brain,  by  the  climacteric,  and  by  old  age,  has  yet  to  be  written  from  the 
physiological  point  of  view.  Many  strange  chapters  on  this  subject  could 
family  doctors  write.  I  have  not  had  a  single  case  of  the  insanity  of  preg- 
nancy in  a  rich  patient  sent  here.  This  is  natural  and  proper,  for  if  any 
kind  of  mental  disease  should  be  kept  out  of  asylums  without  sacrificing 
life  or  recovery,  it  is  this.  It  would  be  a  terrible  fate,  as  things  go  in 
this  world,  to  be  born  in  a  lunatic  asylum,  in  addition  to  being  the  child 
of  an  insane  mother.  The  asylum  cases  cannot  be  taken  as  the  real  type 
of  the  insanity  of  pregnancy. 

The  treatment  of  the  insanity  of  pregnancy  is  in  no  way  special.  The 
women  are  not  usually  run  down.  The  temperature  in  only  four  of  my 
cases  (one  being  the  ursemic  case)  was  above  99°.  Fresh  air,  exercise, 
watching,  nursing,  employment,  cheerful  society,  change,  freedom  from 
too  much  work  and  worry,  and  suitable  food,  are  about  all  we  can  do. 
Slight  sedatives  may  be  required  as  placebos,  but  in  as  small  doses  and 
as  seldom  as  possible.  The  blood  of  an  insane  mother  needs  not  to  be 
mixed  with  morphia  or  chloral  to  make  it  bad  for  her  unborn  progeny. 
The  tendency  to  suicide  must  be  specially  kept  in  mind.  One  of  my 
cases  had  a  secondary  syphilitic  eruption  and  needed  treatment  for  that, 
and  in  two  more  I  suspected  syphilis,  both  children  being  prematurely 
born  dead. 

Together  the  insanities  of  childbed,  nursing,  and  pregnancy  have  con- 
stituted over  nine  per  cent,  of  all  the  female  cases  in  the  Royal  Edinburgh 
Asylum  for  the  past  nine  years  (1874-1882),  there  being  141  cases  out 
of  1549  admissions  (including  readmissions).  There  was  5  per  cent,  of 
the  puerperal  form,  4  per  cent,  of  the  lactational,  and  1  per  cent,  of  the 
insanity  of  pregnancy.  As  we  admit  all  classes  of  society,  this  may  be 
taken  to  represent  the  real  effect  of  childbearing  in  the  production  of  in- 
sanity, at  least  in  this  part  of  the  country.  In  Cumberland  and  AVest- 
moreland  for  the  ten  years  (1863-1872),  during  which  I  was  in  charge 
of  the  Carlisle  Asylum  (for  the  poorer  classes  only),  there  were  75  cases 
out  of  431  female  patients  in  all,  or  17.4  per  cent.  This  enormous  dif- 
ference of  nearly  twice  the  proportion  is  made  up  entirely  of  the  excess 
of  puerperal  cases,  there  having  been  51  of  these,  or  11.8  per  cent,  of 
the  whole  of  the  female  insane  of  those  two  counties.  That  is  more  than 
twice  the  Edinburgh  proportion.  Such  great  differences  in  the  local  dis- 
tribution of  the  different  forms  of  insanity  is  an  interesting  problem  in 
medico-psychology  that  needs  to  be  worked  out  as  to  its  causes. 


LECTURE    XVI. 

THE  INSANITIES  OF  PUBEKTY  AND  ADOLESCENCE. 

When  one  considers  the  enormous  differences  in  the  physiological  life 
and  prevailing  brain  activity  of  the  same  human  being  at  the  different 
periods  of  life,  it  does  not  seem  wonderful  that  each  period  has  its  own 
type  of  psychological  disturbances,  just  as  it  has  its  special  kinds  of  ordi- 
nary disease.  Indeed,  it  would  be  very  wonderful  if  the  brain  of  a  child, 
whose  chief  characteristics  are  active  development,  intense  inquisitive- 
ness  in  all  directions,  great  sensitiveness  to  impressions,  which  succeed 
each  other  rapidly,  and,  whether  they  are  painful  or  pleasurable,  leave 
only  slight  lasting  traces,  if  this  organ  manifested  quite  the  same  dis- 
turbances when  its  mental  functions  become  deranged  as  the  brain  of  an 
old  man,  whose  chief  characteristics  are  retrogression  in  all  its  activities, 
and  insensitiveness  to  ordinary  impressions.  The  essential  qualities  of 
the  two  organs  are  in  many  respects  different ;  their  receptive,  dynamical, 
and  trophic  activities  are  quite  dissimilar.  Then  what  a  change  in  the 
mental  activity  of  the  brain  does  the  period  of  puberty  cause  !  Looking 
at  the  matter  from  the  combined  point  of  view  of  physiologists  and  psy- 
chologists, we  must  connect  the  new  development  of  the  affective  faculties, 
the  new  ideas,  the  new  interests  in  life,  the  new  desires  and  organic 
cravings,  the  new  delight  in  a  certain  sort  of  poetry  and  romance,  with  a 
new  evolution  of  function  in  certain  parts  of  the  brain  that  had  lain 
dormant  before.  This  awakening  into  intense  activity  of  such  vast  tracts 
of  encephalic  tissue,  though  provided  for  in  the  evolution  of  the  organ, 
does  not  take  place  without  risk  of  disturbance  to  its  mental  functions, 
especially  where  there  is  an  inherited  predisposition  in  that  direction. 
And  if  this  predisposition  is  thus  developed  into  actual  derangement  of 
function,  it  happens,  as  might  have  been  surely  predicted  a  priori,  that 
the  type  of  derangement  is  much  influenced  by  the  great  function  of  the 
reproduction  of  the  species  then  arising  de  novo.  To  form  a  right  con- 
ception of  the  kinds  of  mental  disease  that  occur  at  the  various  important 
periods  of  life  it  is  essential  that  we  consider  them  in  connection  with  the 
normal  changes  that  take  place  in  the  organism  at  these  periods,  with 
the  normal  modifications  in  the  mental  energy  at  those  periods,  and 
with  the  changes  that  take  place  in  the  brain  texture  and  mode  of  action, 
so  far  as  we  know  them.  In  short,  we  must  take  a  physiological  view  of 
mental  disease. 

The  Period  of  Puberty  or  Pubescence. — The  period  of  puberty  is 
the  next  great  physiological  era  in  the  life  of  man  after  that  of  birth. 
Before  that  occurs  the  whole  trophic  and  mental  energy  has  been 
occupied  in  acquisition  alone.  There  has  been  no  production.  Before 
that  time  there  has  been  a  general  psychical  likeness  between  individuals 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.  369 

of  the  same  and  of  opposite  sexes  which  then  rapidly  disappears. 
Individualities  of  all  kinds  spring  up  far  more  decidedly  at  that  time  in 
those  of  the  same  sex ;  while,  dividing  the  sexes  at  this  time,  there  arise 
most  striking  psychical  differences  that  far  exceed  the  bodily  contrasts. 
Up  to  that  time  the  mental  development  of  each  sex  has  been  very  much 
in  the  same  direction  ;  after  puberty  that  development  takes  place  in  the 
man  far  more  in  the  direction  of  energizing  and  cognition,  in  the  woman 
in  the  direction  of  emotion  and  the  protective  instincts.  But  these 
changes  do  not  ordinarily  take  place  all  at  once  in  the  human  species, 
any  more  than  a  full  capacity  for  reproduction  takes  place  in  either  sex 
immediately  the  testes  assume  their  function,  or  menstruation  and 
ovulation  are  set  up.  It  takes  several  years  for  the  full  development  of 
the  size  and  form  of  the  body  that  is  normal  and  typical  for  each  sex,  and 
it  takes  still  longer  for  the  complete  evolution  of  the  masculine  and 
feminine  psychical  characteristics.  It  is  not  at  the  time  of  the  first 
appearance  of  the  reproductive  function  chiefly  that  there  is  peril  to  the 
healthy  mental  balance,  but  those  after-years  of  gradual  coming  to 
maturity  are  often  full  of  danger  to  the  mental  health  of  both  sexes.  It 
cannot  be  otherwise.  The  hereditary  influences  and  tendencies  that  all 
the  former  generations  have  transmitted  to  a  man  come  then  most  fully 
into  play.  And  when  we  consider  for  a  moment  that  it  is  not  only  his 
father's  and  his  mother's  own  inherited  tendencies  that  may  come  to  him, 
but  their  acquired  peculiarities  as  well,  and  not  only  so,  but  the  inherited 
and  acquired  peculiarities  of  his  four  grandparents  and  his  eight  great- 
grandparents,  not  to  go  any  further  back,  how  great  a  risk  does  every  man 
and  woman  run  of  suff'ering  for  the  sins  of  their  fathers !  Maudsley 
speaks  of  a  man's  yielding  to  the  tyranny  of  his  organization.  We 
might  go  further,  and  say  he  may  fall  a  victim  to  his  grandfather's 
excesses.  Most  fortunately  for  the  race,  there  are  other  influences 
obviating  such  effects  of  heredity.  One  is  that  the  tendency  towards 
reproducing  the  normal  and  healthy  type  is  generally  stronger  than 
towards  the  abnormal.  If  the  conditions  of  life  are  favorable,  mere  ten- 
dencies never  develop,  and  potentialities  never  become  actualities.  The 
other  is,  that  when  the  tendency  to  abnormality  is  strong  the  victim  of  it 
often  dies  before  the  age  of  reproduction,  or  he  is  incapable  of  procreation. 
Now,  the  insanity  of  puberty  is  always  a  strongly  hereditary  insanity ; 
it,  in  fact,  never  occurs  except  where  there  is  a  family  tendency  towards 
mental  defect  or  towards  some  other  of  the  neuroses.  Its  immediate 
cause  may  be  some  irregularity  in  the  coming  on  of  the  reproductive  or 
menstrual  function ;  its  real  and  predisposing  cause  is  heredity,  having 
for  its  object  this  higher  physiological  law,  that  the  reproduction  of  the 
species  is  stopped  when  the  inherited  tendency  to  brain  disease  acquires  a 
certain  strength  in  any  individual. 

I  cannot  help  here  adverting  to  the  absurd  and  un physiological  theories 
of  education  which  are  sometimes  taught,  and  which  we  as  medical  men 
should  combat  with  all  our  might.  The  old  practice  of  attending  to  the 
acquisitive  and  mnemonic  faculties  of  brain  alone  in  education  is  now 
fortunately  giving  way.  The  theory  of  any  education  worth  the  name 
should  be  to  bring  the  whole  organism  to  such  perfection  as  it  is  capable 
of,  and  to  train  the  brain  power  in  accordance  with  its  capacity,  most 

24 


370         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

carefully  avoiding  any  overstraining  of  weak  points — and  an  apparently 
strong  point  in  the  brain  capacity  of  a  young  child  may  in  reality  be  its 
weakest  point  in  after-life.  I  have  knoAvn  a  child  with  an  extraordinary 
memory  at  eight,  who  at  fifteen  could  scarcely  remember  anything  at  all. 
Then  as  the  age  of  puberty  approaches,  one  would  imagine,  to  hear  some 
scholastic  doctrinaires  talk,  that  it  was  the  right  thing  to  set  ourselves  by 
every  means  to  assimilate  the  mental  faculties  and  acquirements  of  the 
two  sexes,  to  fight  against  nature's  laws  as  hard  as  possible,  and  to  turn 
out  psychically  hermaphrodite  specimens  of  humanity  by  making  our 
young  men  and  women  alike  in  all  respects,  to  make  our  girls  pundits  and 
doctors,  and  our  young  men  mere  examination-passers.  If  there  is  any- 
thing which  a  careful  study  of  the  higher  laws  of  physiology  in  regard  to 
brain  development  and  heredity  is  fitted  to  teach  us,  it  is  this,  that  the 
forcing-house  treatment  of  the  intellectual  and  receptive  parts  of  the 
brain,  if  it  is  carried  to  such  an  extent  as  to  stunt  the  trophic  centres 
and  the  centres  of  organic  appetite  and  muscular  motion,  is  an  unmixed 
evil  to  the  individual,  and  still  more  so  to  the  race.  There  is  no  time  or 
place  of  organic  repentance  provided  by  nature  for  the  sins  of  the  school- 
master. 

Some  educationalists  go  on  the  theory  that  there  is  an  unlimited 
capacity  in  every  individual  brain  for  education  to  any  extent,  in  any 
direction  you  like,  and  that  after  you  have  strained  the  power  of  the 
mental  medium  to  its  utmost,  there  is  plenty  of  energy  left  for  growth, 
nutrition,  and  reproduction.  Nothing  is  more  certain  than  that  every 
brain  has  at  starting  just  a  certain  potentiality  of  education  in  any  one 
direction  and  of  power  generally,  and  that  it  is  far  better  not  to  exhaust 
that  potentiality,  and  that  if  too  great  calls  are  made  in  any  one  direction 
it  will  withdraw  energy  from  some  other  portions  of  the  organ.  These 
persons  forget  that  the  brain,  though  it  has  multiform  functions,  yet  has 
a  solidarity  and  interdependence  through  which  no  portion  of  it  can 
be  injured  or  exhausted  without  in  some  way  interfering  with  the  func- 
tions of  the  other  portions.  Even  the  very  anatomical  and  histological 
composition  of  the  organ  might  teach  us  this.  The  way  in  which 
its  several  elements  that  minister  to  mental  fiinctions,  motion,  sensation, 
regulation  of  temperature,  and  nutrition,  are  mixed  up  in  the  cortex,  and 
even  in  the  centres  lower  down,  have  as  yet  defied  our  anatomical 
and  physiological  investigations  even  to  distinguish  the  one  clearly  from 
the  other.  To  expect  that  any  one  man  could  have  the  biceps  of  a 
blacksmith,  the  reasoning  powers  of  a  Darwin,  the  poetic  feeling  of 
a  Tennyson,  the  procreative  power  of  a  Solomon,  and  the  longevity  of  a 
Parr,  is  simply  to  expect  a  physiological  miracle.  As  Mr.  G.  H.  Lewis^ 
says :  "  Owing  to  the  action  and  reaction  of  blood  and  plasmode, 
of  tissues  on  tissues,  and  organs  on  organs,  and  their  mutual  limitations, 
the  growth  of  each  organism  has  a  limit,  and  the  growth  of  each  organ 
has  a  limit.  Beyond  this  limit  no  extra  supply  of  food  will  increase  the 
size  of  the  organism,  no  increase  of  activity  will  increase  the  (power  of 
the)  organ — 'Man  cannot  add  a  cubit  to  his  stature.'  The  blacksmith's 
arm  will  not  grow  larger  by  twenty  years  of  daily  exercise  after  it  has 

1  Physical  Basis  of  Mind,  p.  184. 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.  371 

once  attained  a  certain  size."  The  possible  extent  of  development  of 
every  brain  and  of  every  function  in  any  one  brain  is  just  as  much  con- 
fined by  limitations  as  the  size  of  the  blacksmith's  arm,  and  physiology 
teaches  us  that  no  organ  or  function  should  be  worked  even  up  to  its  full 
limit  of  power.  No  prudent  engineer  sets  his  safety-valve  just  at  the 
point  above  which  the  boiler  will  burst,  and  no  good  architect  puts  weight 
on  his  beam  just  up  to  the  calculation  above  which  it  will  break.  Nature 
generally  provides  infinitely  more  reserve  power  than  the  most  cautious 
engineer  or  architect.  She  scatters,  for  instance,  seeds  in  millions  for 
hundreds  to  grow,  and  she  is  prodigal  of  material  and  strength  in  the 
heart  and  arteries  beyond  what  is  needed  to  force  the  blood-current 
along ;  therefore  we  have  no  reason  to  think  that  any  function  of  the 
brain  should  be  strained  up  to  its  full  capacity  except  on  extreme 
emergencies,  or  that  any  of  the  receptive  or  sensory  brain-tissues  should 
be  stored  choke-full  of  impressions  for  the  purpose  of  being  frequently 
called  up  again  as  representations.  Especially  do  these  principles  apply 
if  we  have  transmitted  weaknesses  in  any  function  or  part  of  the  organ ; 
and  what  child  is  born  in  a  civilized  country  without  inherited  brain 
weaknesses  of  some  sort  or  in  some  degree  ? 

These  principles  also  apply,  I  believe,  most  strongly  to  the  whole 
reproductive  functions  of  the  body  and  its  centres  in  the  brain,  both  in 
the  male  and  the  female.  Especially  are  they  applicable  in  the  case  of 
the  female  organism,  on  which  the  chief  strain  of  reproducing  the  species 
rests.  The  risks  to  the  mental  functions  of  the  brain  from  the  exhaust- 
ing calls  of  menstruation,  maternity,  and  lactation,  from  the  nervous 
reflex  influences  of  ovulation,  conception,  and  parturition,  are  ruinous  if 
there  is  the  slightest  original  predisposition  to  derangement,  and  the 
nonnally  profound  influences  on  all  the  brain  functions  of  the  great  ei'as 
of  puberty  and  the  climacteric  period  are  too  apt,  in  these  circumstances, 
to  upset  the  brain  stability.  Beyond  all  doubt,  boarding-school  education 
has  not  as  yet  been  conducted  on  physiological  principles,  and  is  respon- 
sible for  much  nervous  and  mental  derangement,  as  well  as  for  difficult 
maternity  ;  but  if  the  education  of  civilized  young  women  should  become 
what  some  educationalists  would  wish  to  make  it,  all  the  brain  energy 
would  be  used  up  in  cramming  a  knowledge  of  the  sciences,  and  there 
would  be  none  left  at  all  for  trophic  and  reproductive  purposes.  In  fact, 
for  the  continuance  of  the  race  there  would  be  needed  an  incursion  into 
lands  where  educational  theories  were  unknown,  and  where  another  rape 
of  the  Sabines  was  possible.  American  physicians  tell  us  that  there  are 
some  schools  in  Boston  that  turn  out  young  ladies  so  highly  educated 
that  every  particle  of  their  spare  fat  is  consumed  by  the  brain-cells  that 
subserve  the  functions  of  cognition  and  memory.  If  these  young  women 
do  marry,  they  seldom  have  more  than  one  or  two  children,  and  only 
puny  creatures  at  that,  whom  they  cannot  nurse,  and  who  either  die  in 
youth  or  grow  up  to  be  feeble-minded  folks.  Their  mothers  had  not  only 
used  up  for  another  purpose  their  own  reproductive  energy,  but  also  most 
of  that  which  they  should  have  transmitted  to  their  children ;  nature,  no 
doubt,  making  provision  for  the  transmission  of  the  unused-up  energy  of 
one  generation  on  to  the  next,  on  the  principle  of  the  conservation 
of  force.     As  physicians — the  priests  of  the  body  and  the  guardians  of 


372  INSANITIES    OF    PUBERTY     AND    ADOLESCENCE. 

the  physical  and  mental  qualities  of  the  race — we  are,  beyond  all  doubt, 
bound  to  oppose  strenuously  any  and  every  kind  and  mode  of  education 
that  in  any  way  lessen  the  capability  of  woman  for  healthy  maternity, 
and  the  reproduction  of  future  generations  strong  mentally  and  physically. 
Why  should  we  spoil  a  good  mother  by  making  an  ordinary  grammarian  ? 
The  relation  of  the  psychical  and  emotional  development  to  the  generative 
function  is  full  of  interest  and  importance  to  us  as  physiologists,  and  few 
men  have  been  long  in  practice  before  such  questions  obtrude  themselves 
as  very  practical  ones  indeed.  The  first  hysterical  girl  a  man  has  to  treat 
in  a  good  family,  where  he  does  not  want  to  lose  the  case  or  the  family 
practice,  may  test  severely  his  knowledge  of  the  reflex  relationship  of  the 
uterus  with  the  sensory,  motor,  and  mental  functions  of  the  brain.  We 
must,  as  much  as  we  can,  study  the  conditions  and  relations  of  phenomena 
of  all  kinds.  It  is  a  mere  cloak  for  ignorance,  and  an  excuse  for  not 
thinking,  to  call  certain  abnormal  phenomena  "hysterical,"  and  imagine 
that  explains  them.  It  does  not  require  much  consideration  to  see  that 
at  the  period  of  puberty  in  both  sexes,  but  especially  in  the  female,  the 
direct  connection  of  certain  physiological  functions  and  processes  with 
certain  mental  facts  influences  the  whole  life  of  the  individual.  If  that 
connection  is  in  any  way  abnormal,  we  have  great  strains  on  the  mental 
functions  of  the  brain,  and  sometimes  actual  derangement.  Our  high 
civilization  and  refinement,  no  doubt,  add  immensely  to  the  risks  by 
increasing  the  strain.  The  psychological  analysis  of  what  female 
modesty  is,  by  a  physiologist,  reveals  the  transformation  and  apotheosis  in 
the  higher  regions  of  the  brain  of  reflex  impressions  from  the  reproductive 
organs  into  a  high  moral  quality,  not  only  beautiful,  but  absolutely 
essential  to  social  life.  How  can  a  physician  understand  the  true  import 
of  the  obtrusive  and  grotesque  modesty  of  a  hysterical  patient  except  he 
takes  this  into  account  ?  The  intense  and  complete  outward  repression 
and  inhibition  of  certain  physiological  cravings  required  by  our  morals 
and  our  civilization  cause,  no  doubt,  a  dangerous  strain  on  the  brain 
functions,  and  a  reaction  in  other  directions,  where  there  are  hereditary 
neurotic  weaknesses. 

Puberty  is  the  first  really  dangerous  period  in  the  life  of  both  sexes  as 
regards  the  occurrence  of  insanity;  but  it  is  not  nearly  so  dangerous  as 
the  period  of  adolescence,  a  few  years  afterwards,  when  the  body,  as  well 
as  the  functions  of  reproduction,  have  more  fully  developed.  The  nutri- 
tive energy  of  the  brain  is  so  great  in  youth,  its  recuperative  power  so 
vigorous,  and  its  capacity  for  rest  in  sleep  so  powerful,  that  its  mental 
functions  are  not  often  upset  at  this  period.  To  bring  out  this  fact 
statistics  are  useful.  In  Scotland,  at  the  present  time,  nearly  one-half 
the  population  are  under  the  age  of  20 ;  while  in  the  Royal  Edinburgh 
Asylum  we  have,  out  of  a  total  of  730  patients,  only  ten  under  that  age. 
The  contrast  between  50  per  cent,  and  1.5  per  cent,  in  the  sane  and 
insane  populations  is  a  very  marked  one.  But,  to  show  how  different  is 
the  state  of  matters  in  the  older  periods  of  life,  let  us  compare  the  num- 
ber of  persons  over  60  in  Scotland  and  in  the  asylum.  In  the  general 
population  there  are  just  about  8  per  cent,  over  that  age,  while  in  the 
asylum,  out  of  the  730,  there  are  no  less  than  126,  or  17  per  cent.  Or, 
to  bring  out  the  facts  differently,  it  is  found  that  the  number  of  people 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.         373 

SO  insane  as  to  require  to  be  sent  to  asylums  is  about  one  in  600  of  the 
population.  Now,  at  this  rate,  our  730  inmates  represent  an  ordinary 
population  of  438,000.  One-half  of  these,  or  219,000  persons,  are  20 
years  of  age  or  under,  and  they  have  only  supplied  ten  of  our  lunatics, 
insanity  occurring  in  them  at  the  rate  of  only  one  in  21,900,  while  the 
remaining  half  of  the  general  population,  that  over  20,  had  produced  720 
lunatics,  or  one  in  304,  that  is,  in  seventy  times  the  proportion  of  those 
under  20  years  of  age.  After  the  age  of  20  there  is  no  such  enormous 
disproportion  in  the  production  of  lunacy.  It  is  undoubtedly  most  fre- 
quent between  the  ages  of  35  and  55.  Speaking  generally,  therefore, 
insanity  in  its  worst  forms  is  not  a  disease  of  youth  or  puberty,  but  of 
middle  and  advanced  life.  Slight  attacks  of  nervous  and  mental  de- 
rangement, however,  that  do  not  require  asylum  treatment,  are  by  no 
means  uncommon  in  those  predisposed  to  the  neuroses  at  the  earlier 
ages,  especially  in  the  female  sex ;  and  if  the  general  health  and  strength 
and  nutrition  are  poor,  puberty  is  liable  to  cause  neurotic  symptoms  in 
those  cases.  Such  symptoms,  if  there  is  an  inherited  predisposition  to 
insanity,  should  by  no  means  be  despised.  They  may  develop  into 
actual  insanity  at  a  later  period.  For  the  production  of  decided  insanity 
requiring  asylum  treatment  at  the  age  of  puberty,  we  must,  as  I  said, 
have  a  strong  neurotic  predisposition,  as  well  as  the  advent  of  the  repro- 
ductive era  and  the  changes  it  brings  along  with  it.  I  have  scarcely  ever 
met  with  a  case  without  this.  Other  affections  of  the  nervous  centres 
are  very  apt  to  appear  at  this  period  of  life,  notably  the  two  great 
derangements  of  the  motor  centres,  epilepsy  and  chorea.  The  motor 
centres  are,  no  doubt,  more  unstable  and  easily  upset  in  their  working  in 
youth  than  either  the  mental,  sensory,  or  trophic  centres.  Infantile 
convulsions  are  the  nervous  disease  of  infancy.  I  believe  that  if  there 
is  a  hereditary  predisposition  to  any  neurosis  whatever  in  infancy,  it  most 
frequently  shows  itself  in  a  special  tendency  to  infantile  convulsions 
during  dentition.  We  find  that  the  majority  of  cases  of  epilepsy  and 
chorea  in  the  female  begin  at  the  period  of  puberty.  The  insanity  of 
puberty  in  both  sexes  is  characterized  especially  by  motor  restlessness. 
Such  patients  never  sit  down  by  night  or  day,  and  never  cease  moving. 
There  is  noisy  and  violent  action,  sometimes  irregular  movements,  or,  in 
the  few  melancholic  forms  and  melancholic  stages  of  the  maniacal  cases, 
cataleptic  rigidity.  The  mental  symptoms  consist  most  frequently  of  a 
kind  of  incoherent  delirium  rather  than  any  fixed  delusional  state.  In 
boys,  the  beginning  of  an  attack  is  frequently  ushered  in  by  a  disturb- 
ance in  the  emotional  condition,  dislikes  to  parents  or  brothers  or  sisters 
expressed  in  a  violent,  open  way;  there  is  irrational  dislike  to,  and 
avoidance  of,  the  opposite  sex.  The  manner  of  a  grown-up  man  is 
assumed,  and  an  offensive  "forwardness"  of  air  and  demeanor.  This 
soon  passes  into  maniacal  delirium,  which,  however,  is  not  apt  to  last  long. 
It  alternates  with  periods  of  sanity,  and  even  with  stages  of  depression. 

This  is  one  of  the  most  characteristic  cases  of  the  early  insanity  of 
puberty  I  have  met  with.  I  have  seen  others  presenting  the  same  pecu- 
liar symptoms : 

K.  P.,  aet.  V\.\,  of  an  active  and  cheerful  disposition,  and  a  bright  boy 
at  school.    His  parents  were  poor,  and  he  was  brought  up  in  a  poor  part 


874         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

of  the  town.  His  mother  had  an  attack  of  puerperal  insanity  (mania) 
after  the  birth  of  a  child  born  before  K.  P.,  and  another  attack  of  ordi- 
nary acute  delirious  mania  after  he  had  been  sent  to  the  asylum,  from 
both  of  which  she  recovered.  He  has  an  elder  brother  who,  at  the  age 
of  nineteen,  had  an  attack  of  acute  adolescent  insanity  (mania),  and 
became  demented,  and  is  now  in  the  asylum.  There  was  no  exciting 
cause  of  the  boy's  illness.  He  caught  a  feverish  cold,  and  then  became 
exalted  in  mind,  singing  continuously,  clinging  to  his  mother,  saying  he 
was  going  to  heaven.  This  continued  all  day,  but  at  night  he  slept 
twelve  houi-s,  and  he  took  his  food  as  usual.  When  sent  to  the  asylum 
there  was  a  very  peculiar  mixture  of  mental  exaltation  and  depression 
present.  He  went  on  all  the  time  singing  joyful  hymns  in  lively  tunes, 
but  in  a  voice  as  if  crying.  He  would  not  answer  questions  or  take 
any  notice  of  anything  about  him,  and  could  not  be  made  to  attend  to 
anything  any  more  than  if  he  had  been  in  a  condition  of  trance.  His 
whole  condition  was  one  of  almost  mental  automatism,  and  as  he  sang  he 
would  rock  himself,  and  keep  time  rhythmically  with  his  hands  and  body. 
If  anyone  put  their  arms  round  him,  he  would  cuddle  up  to  them,  and  in 
a  child's  whining  voice  sing,  "  Tak  me  to  ma  mammy.  Oh,  my  bonny 
mammy,  my  bonny  mammy;  come  to  me,  mammy.  Have  mercy  on 
me,"  etc.,  over  and  over  again,  in  a  rhythmical  way;  and  if  his  eyes 
were  shut  and  covered  up  he  would  go  right  off  to  sleep.  The  moment 
he  awoke,  the  singing  would  begin.  If  he  were  much  interfered  with, 
he  would  shout  and  resist  in  a  sort  of  unconscious  way.  He  was  poorly 
nourished  and  weak  in  body.  He  was  sent  out  in  the  open  air  much, 
and  was  ordered  a  large  quantity  of  milk  and  cod-liver  oil  emulsion.  In 
about  seven  days  the  state  of  delirium  passed  off,  and  he  got  quite  well 
mentally.  His  father  took  him  home  in  three  weeks,  but  he  got  into 
precisely  the  same  state  again  on  finding  his  mother  insane  at  home  and 
unable  to  speak  to  him.  His  mother  was  taken  to  the  asylum,  and  he 
took  the  delusion  that  his  father,  too,  was  dead  and  gone.  In  about  a 
fortnight  he  passed  out  of  the  delirium,  and  became  quite  cheerful  and 
active.  Just  four  weeks  and  two  days  after  his  second  admission,  he 
complained  first  of  toothache,  and  then  almost  immediately  became  very 
excited,  and  said  he  could  not  see,  sobbed,  shouted,  and  was  with  diffi- 
culty restrained  from  throwing  himself  about.  The  symptoms  were  more 
those  of  ordinary  acute  mania,  but  with  some  of  the  former  delusions, 
automatism,  and  facility  for  sleeping.  This  attack  lasted  for  a  few  days 
only.  He  then  remained  well  for  exactly  four  months,  and  then  had 
another  attack,  preceded  by  dilatation  of  the  pupils  and  dimness  of 
vision.  The  attack  lasted  for  three  days.  He  then  got  well  again,  but 
in  another  montb  to  a  day  he  got  excited  and  emotional  again.  Though 
his  face  looked  sad,  and  his  voice  was  that  of  weeping,  he  never  shed 
tears.  This,  the  fifth,  was  the  last  attack  he  had ;  after  that  he  kept  well, 
was  sent  home,  and  has  now  been  there  for  more  than  a  year.  During 
the  whole  of  the  time  he  was  in  the  asylum  he  was  getting  stronger  and 
fatter,  and  was  a  well-nourished,  cheerful  boy,  with  no  peculiarities  what- 
ever, when  he  left. 

The  chief  features  of  this  case  were — (1)  the  suddenness  of  the  coming 
on  of  the  mental  attacks,  without  external  cause ;  (2)  the  curious  auto- 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.         875 

matic  delirious  character  of  them,  the  mixture  of  exalted  feeling  with  de- 
pression, and  the  impossibility  of  rousing  his  attention  to  anything  outside 
of  him ;  (3)  the  way  in  which  he  went  off  to  sleep  when  his  eyes  were 
closed  and  an  arm  was  put  round  him,  in  both  these  respects  resembling 
hypnotism  ;  (4)  the  repetition  of  the  attacks  in  irregular  monthly  periods; 
(5)  his  complete  recovery  at  last. 

I  look  on  such  a  case  as  an  example  of  the  evolution  of  a  new  function, 
that  of  generation,  upsetting  the  convolutional  working  of  a  brain  strongly 
predisposed  by  heredity  to  insanity.  The  physiological  problem  solving 
in  the  brain  at  this  time  seemed  to  be — Shall  the  organism  have  power 
to  reproduce  itself?  or  shall  it  die  in  its  highest  function  (mentalization) 
in  the  process  of  the  evolution  of  the  power  to  reproduce  ?  His  elder 
brother  had  been  attacked  with  insanity,  not  at  puberty,  but  during 
adolescence,  at  the  age  of  nineteen.  He  had  at  first  exhibited  a  good 
many  cataleptic  symptoms,  a  motor  automatic  condition,  just  as  K.  P. 
had  many  mental  automatic  symptoms.  In  each  case  the  "  higher 
centre"  of  volition  was  powerless.  The  brother,  after  being  maniacal 
for  about  two  years  in  periodic  intervals,  has  sunk  into  dementia.  In 
him  nature  has  stopped  the  reproduction  of  the  species. 

The  treatment  I  look  on  as  an  attempt  so  to  strengthen  the  vital  forces 
and  the  nutrition  of  the  organism,  that  it  shall  pass  through  the  whole 
period  of  the  evolution  of  the  new  function  without  undergoing  the  risk 
of  the  destruction  of  all  the  higher  mental  faculties. 

K.  P.'s  case  was  no  doubt  in  the  very  earliest  stage  of  puberty,  and, 
indeed,  in  some  of  its  mental  characters  partook  of  some  of  the  charac- 
teristics of  the  delirium  of  childhood. 

Adolescence. — The  mental  disturbance  characteristic  of  this  period 
is  closely  allied  to  that  which  occurs  at  puberty.  It  occurs  later,  between 
the  ages  of  eighteen  and  twenty-five,  notably  between  twenty  and  twenty- 
five,  when  the  function  of  reproduction  is  attaining  its  full  development 
and  the  body  is  arriving  at  its  full  growth.  That  there  is  such  an  era  in 
life  physiologically  is  sufficiently  proved  by  the  existence  in  all  languages 
of  a  word  to  signify  the  same  thing  as  our  "  adolescence."  I  cannot  hope 
to  change  the  accepted  meaning  of  the  present  nomenclature,  but  I  would, 
if  I  could,  distinguish  between  puberty  and  adolescence  in  this  way — I 
should  restrict  puberty,  as  is  now  done  when  the  term  is  used  in  a  scien- 
tific and  physiological  sense,  to  the  initial  development  of  the  function  of 
reproduction,  and  to  its  first  appearance  as  an  energy  of  the  organism ; 
while  I  should  use  adolescence  to  denote  the  whole  period  of  twelve  years 
from  the  first  evolution  up  to  the  full  perfection  of  the  reproductive  energy, 
when  the  bones  are  finally  consolidated,  and  the  full  growth  of  the  beard 
and  the  sexual  hair  takes  place,  and  there  occurs  the  perfect  assumption 
of  the  manly  form  in  the  male  sex,  and  the  full  development  of  the  adipose 
tissue  and  the  mammas  gives  the  female  form  its  perfect  grace  of  contour. 

Dr.  Mathews  Duncan  has  proved  statistically  that  in  the  female  sex 
"the  climax  of  initial  fecundity,"  which  may  be  taken  as  proof  of  full 
development,  "  is  about  the  age  of  twenty -five  years.  "^  This  may  be 
assumed  to  be  the  case  for  both  sexes. 

1  Fecundity,  Fertility,  and  Sterility,  2d  ed.,  p.  33. 


876         INSASTTIBS   OF    PFBKRTT    AND    ADOLKSCKJTCE . 

Looked  at  firom  a  psychological  point  of  view,  it  can  scarcely  be  denied 
by  anyone  that  the  later  years  of  adolescence  are  far  more  important 
than  the  first.  For  years  after  puberty  boys  and  girls  are  still  boys  and 
girls  in  mind,  but  as  a  physiological  fact  the  female  sex  attains  its  full 
bodily  development  first.  At  twenty-one  the  great  majority  of  that  sex 
hare  attained  perfect  physiological  development,  and  Duncans  statistics 
show  that  their  initial  fecundity  is  then  almost  at  its  climax.  But  this 
is  not  so  in  the  male  sex.  The  growth  of  the  beard  and  the  form  of  the 
body  do  not  reach  foil  development  in  that  sex  on  an  average  till  the  age 
of  tweaty-five.  Mentally  the  difference  is  still  more  marked.  The  subtle 
but  profound  mental  influences  of  adolescence  have  usually  reached  their 
foil  maturity  in  women  three  or  four  years  before  men.^ 

A  carefol  study  of  human  nature  will  soon  show  any  observer  that  the 
period  of  adolescence  in  this  sense  is  a  most  momentous  one.  The  mental 
diange  that  takes  place  from  eighteen  to  twenty-five  is  incomparably  more 
important,  and  I  think  more  interesting  psychologically,  too.  than  that 
wludi  occurs  between  fourteen  and  eighteen.  The  psychological  change 
at  puberty  is,  no  doubt,  great  from  childhood;  but  it  is  inchoate  and 
nascent ;  it  wants  precision  and  conscious  power ;  its  emotionalism  is 
utterly  spasmodic  and  childish ;  its  sentiment  wants  tenderness,  and  its 
ambitions  and  longinofs  are  mere  castle-building  in  the  air. 

At  adolescence  in  the  male  sex  life  first  begins  to  look  serious,  both 
from  the  emotional  side  and  in  action.  It  is  then  only  that  childish 
diings  are  put  away.  For  the  first  time  is  literature,  in  any  correct 
sense,  appreciated.  Poetry,  not  even  understood  before,  now  becomes  a 
passion,  at  least  certain  kinds  of  poetry.  Not  that  the  highest  kind  of 
literature  is  reached.  No  adolescent  ever  really  appreciated,  or  even 
thoroughly  liked,  Shakespeare,  That  is  reserved  for  foil  manhood. 
The  kind  of  novel  that  is  enjoyed  is  always  a  good  test  of  the  mental 
and  emotional  development.  The  boy  enjoys  Ballantyne  and  Marryat; 
G-  P.  R,  James  b^ns  to  have  a  dim  meaning  to  the  youth  :  at  puberty 
the  adolescent  takes  to  Scott,  Dickens,  and  Miss  Austin :  while  only  the 
man  enjoys  and  understands  Shakespeare,  George  Eliot,  and  Thackeray. 
Go  into  a  university  and  watch  the  demeanor  of  the  first  and  fourth 
year's  man.  if  anyone  has  any  doubt  as  to  the  immeasurable  distance 
between  puberty  and  adolescence.  There  seems  to  be  a  great  gulf  fixed 
between  th«n.  The  fourth  year's  man  treats  his  junior  not  as  a  mere 
junior,  but  as  of  a  different  and  inferior  species.  He  never  speaks  to 
him  if  he  can  help  it ;  he  would  no  more  room  with  him  than  he  would 
with  a  baby  in  arms.  Watch  the  two  in  the  presence  of  the  opposite  sex. 
Their  behavior  is  quite  different.  In  the  one  case  you  see  mere  shyness, 
that  breaks  out  into  rollicking  fun  the  moment  a  real  acquaintance  is 
fivmed;  in  the  other  there  is  real  sexual  egoism,  that  most  painfol 
l^easnre  that  consists  of  the  half  unconscious  organic  feeling  that  each 
person  of  one  sex  is  an  object  of  the  most  intense  interest  to  each  person 
of  the  opposite  sex  about  the  same  age.  The  real  events  and  possibilities 
of  the  foture  are  reflected  in  vague  and  dreamlike  emotions  and  longings, 
tiiat  have  much  bliss  in  them,  but  not  a  little,  too,  of  seriousness  and  diffi- 

»  See  Edinburgh  Medical  JouimI,  July,  1879,  "The  Stody  of  Mental  Diseases," 
by  the  anthor. 


IjrSANITIES    OF    PUBEBTY    AXD    ADOLESCENCE.         377 

culty.  The  adolescent  feels  instinctively  that  he  has  now  entered  a  new 
country,  the  face  of  which  he  does  not  know,  but  yet  that  is  full  of  possi- 
bility of  good  and  happiness  for  him.  He  has  a  craving,  too,  for  action 
of  some  sort — not  merely  the  football  action  of  the  boy,  but  something  of 
more  serious  import.  Longfellow's  youth  that  vaguely  cried  "'Excelsior" 
was  evidently  at  thLs  stage  of  life.  His  reasoning  faculty  first  gets  some 
backbone  at  this  period.  His  emotional  nature  acquires  for  the  first  time 
a  leaning  towards  the  other  sex  that  quite  swallows  up  the  former  emo- 
tions. It  is  not  yet  at  all  under  his  control,  fixed  or  definite  in  its  aims. 
His  sense  of  the  seriousness  and  responsibility  of  life  may  be  said  to 
awake  then  for  the  first  time  in  a  real  sense.  The  first  sense  of  right 
and  wrong  and  of  duty  becomes  then  more  active  instead  of  passive.  He 
has  yearnings  after  the  good,  and  is  capable  of  an  intense  hatred  and 
scorn  of  evil  which  he  could  not  have  experienced  before. 

But  it  is  in  the  female  sex  that  the  period  of  adolescence  has  attracted 
most  attention,  especially  among  those  psychological  students  and  deline- 
ators of  character,  the  novelists  of  the  day.  As  physicians,  we  know 
that  it  is  only  then  that  hysteria,  migraine,  and  the  graver  functional 
and  reflex  neuroses  arise.  As  men  of  the  world,  we  know  that  the  love- 
making,  the  flirting,  the  engagements  to  marry,  and  the  broken  hearts 
of  the  adolescents  are  not  reallv  very  serious  affairs.  The  cataclasms  of 
life  do  not  happen  then.  We  know  that  no  artist  ever  painted,  or  no 
sculptor  ever  modelled,  a  Venus  who  had  not  passed  adolescence.  A  very 
fine  and  most  interesting  study  of  adolescence  in  the  female  sex  is,  in  my 
opinion,  to  be  found  in  the  Gwendolen  Harleth  of  George  Eliot's  novel 
of  Daniel  Deranda.  This  authoress  was  by  far  the  most  acute  and 
subtle  psychologist  of  her  time,  and  certainly  the  character  I  have  men- 
tioned is  most  worthy  of  study  by  all  physicians  who  look  on  mind  as 
being  in  their  field  of  study  or  sphere  of  action.  From  the  time  when, 
at  the  gaming-table,  Gwendolen  caught  Deronda's  eye,  and  was  totally 
swayed  in  feeling  and  action  by  the  presence  of  a  person  of  the  other  sex 
whom  she  had  never  seen  before;  playing,  not  because  she  liked  it  or 
wished  to  win,  but  because  he  was  looking  on,  all  through  the  story  till 
her  marriage,  there  is  a  perfect  picture  of  female  adolescence.  The 
subjective  egoism  tending  towards  objective  dualism,  the  resolute  action 
firom  instinct,  and  the  setting  at  defiance  of  calculation  and  reason,  the 
want  of  any  definite  desire  to  marry,  while  all  her  conduct  tended  to 
promote  proposals,  the  selfishness  as  regards  her  relations,  even  her 
mother,  and  the  organic  craving  to  be  admired,  are  all  true  to  nature. 
Witness  her  state  of  mind  when  Grandcourt  first  appeared: 

"  Hence  Gwendolen  had  been  all  ear  to  Lord  Brackenshaw's  mode  of  accoantin^ 
for  Grandcooit't  tHMHappearanee ;  and  when  he  did  arrive,  no  consciousness  was  more 
awake  to  the  ftet  tlmi  nets,  ahhougfa  she  steadily  avoided  l<x>king  towards  any  point 
where  he  was  likely  to  be.  There  should  be  no  slightest  shifting  of  angles  to  betray 
that  it  was  of  any  consequence  to  her  whether  the  much-talked-of  Mr.  Malliiiger 
Grandcourt  presented  himself  or  not.  And  all  the  whUe  the  certainty  that  he  was 
tiiere  made  a  distinct  thread  in  her  consciousness." 

Again : 

"  Gwendolen  knew  cotain  differences  in  the  characters  with  which  she  was  con- 
eemed  as  hizds  know  rlimate  and  weather." 


378         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

The  sentimentality  of  this  period  of  life  is  well  illustrated  when  Gwen- 
dolen says : 

"  '  I  never  saw  a  married  woman  who  had  her  own  way.'  '  What  should  you  like 
to  do?'  said  Alex,  quite  guilelessly,  and  in  real  anxiety.  [He  was  an  adolescent  just 
entering  on  the  period.]  '  Oh,  I  don't  know  !  Go  to  the  North  Pole,  or  ride  steeple- 
chases, or  go  to  be  a  queen  in  the  ball,  like  Lady  Hester  Stanhope,'  said  Gwendolen 
flightly.  '  You  don't  mean  you  would  never  be  married.'  '  No,  I  didn't  say  that. 
Only,  when  I  married,  I  should  not  do  as  other  women  do.'  " 

The  inchoate  religious  sentiment,  as  a  psychological  faculty  contending 
with  the  egoism,  is  thus  brought  out : 

"  What  she  unwillingly  recognized,  and  would  have  been  glad  for  others  to  be  un- 
aware of,  was  that  liability  of  hers  to  fits  of  spiritual  dread.  .  .  .  She  was  ashamed 
and  frightened  as  at  what  might  happen  again,  in  remembering  her  tremor  on  sud- 
denly finding  herself  alone  .  .  .  Solitude  in  any  wide  scene  impressed  her  with 
an  undefined  feeling  of  immeasurable  existence  aloof  from  her,  in  the  midst  of  which 
she  was  helplessly  incapable  of  asserting  herself.  With  human  ears  and  eyes  about 
her,  she  had  always  hitherto  recovered  her  confidence,  and  felt  the  possibility  of  win- 
ning empire." 

The  selfishness  and  craving  for  notice  are  thus  hit  off: 

"  I  like  to  differ  from  everybody.  I  think  it  is  stupid  to  agree." 
"  Her  thoughts  never  dwelt  on  marriage  as  the  fulfilment  of  her  ambition.  .  .  . 
Her  observation  of  matrimony  bad  induced  her  to  think  it  rather  a  dreary  state,  in 
which  a  woman  could  not  do  as  she  liked,  had  more  children  than  were  desirable,  was 
consequently  dull,  and  became  irrevocably  immersed  in  humdrum.  Of  course,  mar- 
riage was  social  promotion.  She  could  not  look  forward  to  a  single  life.  .  .  .  She 
meant  to  do  what  was  pleasant  to  herself  in  a  striking  manner;  or  rather,  whatever 
she  could  do  so  as  to  strike  others  with  admiration,  and  get  in  that  way  a  more  ardent 
sense  of  living,  seemed  pleasant  to  her  fancy." 

But  extracts  merely  spoil  the  whole  picture,  which  is  one  that  is  in 
perfect  accord  with  the  facts  of  nature,  drawn  by  a  consummate  artist. 
It  is  one  of  the  most  perfect  psychological  studies  with  which  I  am 
acquainted. 

It  seems  like  passing  from  the  poetry  of  science  to  Dryasdust's  details, 
to  descend  from  George  Eliot's  word-pictures  to  the  details  of  physio- 
logical fact  and  speculation  that  underlie  all  this  charming  maiden's 
mental  constitution.  I  think  most  medical  men  of  extensive  observation 
would  agree  with  me,  that  the  incompleteness  of  those  mental  tokens  of 
merely  developing  womanhood  and  manhood  during  the  period  of  adoles- 
cence do  indicate  that  the  conditions  under  which  the  reproduction  of 
the  species  takes  place  should  be  deferred  till  adolescence  has  passed. 
The  love-making  of  adolescence  is  not  the  serious  matter  it  should  be,  as 
Gwendolen's  history  well  shows ;  and,  therefore,  the  full  physiological 
and  psychological  conditions  for  dualism  not  being  there,  it  should  not  be 
encouraged.  All  serious  love-making,  engagements  to  marry,  too  free 
intercourse  with  the  other  six,  too  much  dancing,  too  much  going  into 
society,  merely  tend  to  force  on  the  full  development,  like  young  plants 
in  a  hothouse,  with  the  result  that  the  flowers  and  fruits  have  a  tinge  of 
artificialness,  do  not  last,  do  not  stand  the  same  tear  and  wear.  A  young 
man  who  marries  before  his  beard  is  fully  grown  breaks  a  law  of  nature 
and  sins  against  posterity.  A  girl  who  gets  engaged  while  in  Gwen- 
dolen's state  of  mind  is  not  likely  to  derive  all  the  happiness  in  marriage 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE,         379 

of  which  she  is  capable.  It  follows,  therefore — and  most  members  of  our 
profession  would,  I  think,  agree  with  me — that  sexual  intercourse  should 
not  be  indulged  in  till  after  adolescence. 

The  period  of  adolescence  is  very  liable  to  those  psychological  cata- 
clasms  in  weak  brains,  attacks  of  mania,  that  have  a  special  relationship 
to  the  function  of  reproduction.  Especially  it  seems  to  me  that  the 
periodicity  and  remission  of  the  nisus  ffenerativus  in  both  sexes,  and  the 
menstrual  periodicity  which  accompanies  it  in  females,  are  reflected  in  a 
periodicity  and  tendency  to  remission  in  the  insanity  that  occurs  during 
adolescence. 

Passing  now  from  the  physiological  and  psychological  characteristics 
of  adolescence  to  the  forms  of  mental  disease  that  prevail  then,  the  fol- 
lowing was  a  very  severe  case  of  the  insanity  of  adolescence  terminating 
in  recovery :  K.  Q.,  oet.  23,  a  student,  who  worked  hard,  who  had  a 
neurotic  heredity,  whose  life  had  been  sedentary,  and  whose  bodily  health 
and  nutrition  had  run  down.  It  was  feared,  too,  he  had  been  given  to 
the  habit  of  masturbation.  He  had  been  working  extra  hard  to  pass  an 
examination,  when  suddenly,  without  any  other  exciting  cause,  he  became 
morbidly  exalted,  lost  his  power  of  sleep,  got  restless,  talkative,  violent, 
and  unmanageable  at  home.  Within  four  days  he  had  to  be  sent  to  the 
asylum.  He  then  labored  under  acute,  almost  delirious,  mania.  He  was 
exalted,  giving  incoherent  descriptions  of  metaphysical  speculations  and 
mental  problems.  There  was  a  great  deal  of  the  sexual  element  running 
through  his  incoherence  and  his  speculations.  His  temperature  was 
100.1°;  his  pulse  84,  weak;  his  weight  eleven  stone  twelve  pounds.  He 
was  kept  outside  nearly  all  day  in  charge  of  two  good  attendants,  though 
most  violent ;  he  was  compelled  to  take  four  custards  a  day,  each  con- 
taining four  eggs  and  a  pint  and  a  half  of  milk,  in  addition  to  any  ordi- 
nary food  he  could  be  got  to  take.  He  was  treated  with  warm  baths  at 
night,  with  cold  to  his  head,  and  large  doses  of  bromide  and  iodide  of 
potassium  combined  while  the  temperature  was  high.  He  slept  little, 
and  in  spite  of  the  enormous  quantity  of  nourishment  taken  he  fell  off 
in  flesh  and  strength.  Contrary  to  my  usual  custom  in  adolescent  cases, 
I  added  a  considerable  quantity  of  port  wine  to  his  diet,  as  he  looked  at 
times  so  exhausted.  In  the  first  six  weeks  of  his  stay  in  the  asylum  he 
lost  two  stone  in  weight.  All  kinds  of  sedatives  were  tried  temporarily 
in  vain.  I  thought  he  was  going  to  die  of  exhaustion.  He  had  a  slight 
beginning  of  a  haematoma,  which  was  blistered,  and  so  stopped.  The 
excitement  was  paroxysmal  and  recurrent  in  its  intensity,  though  he  was 
never  free  from  it.  After  about  two  months  the  intensity  of  the  maniacal 
condition  began  to  abate,  and  he  passed  into  what  is  to  me  a  most  anxious 
stage  in  these  cases.  His  expression  of  face  became  enfeebled  looking, 
his  habits  dirty,  he  masturbated  badly,  and  his  whole  mental  state  sug- 
gested dementia  rather  than  either  mania  or  recovery.  One  cannot  pay 
sufficient  attention  to  the  treatment  of  such  symptoms  in  that  stage.  The 
nourishment  was  made  a  little  more  stimulating  by  strong  soups,  in  addi- 
tion to  the  milk  and  eggs.  He  got  fresh  vegetables,  cod-liver  oil,  with 
the  hypophosphites,  and  strychnine  and  iron.  He  was  narrowly  watched 
and  well  nursed,  and  much  moral  treatment  adopted  to  rouse  and  interest 
him.     It  was  in  truth  a  toss  up  between  recovery  and  dementia,  between 


880         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

mental  life  and  mental  death.  Fortunately  the  recuperative  power  of  his 
brain  and  constitution  prevailed,  he  slowly  picked  up  flesh,  and  his  beard 
and  whiskers  began  to  sprout — I  have  much  faith  in  adolescent  recoveries 
when  the  beard  has  grown  coincidently  with  recovery — and  his  weight 
increased  fast  and  steadily,  until  in  six  months  from  the  commencement 
of  his  illness  he  was  quite  well  in  mind,  and  strong  and  stout  in  body, 
weighing  thirteen  stones.  This  was  one  of  only  about  six  patients  that  I 
have  seen  where  recovery  took  place  after  a  hsematoma  had  formed  or 
even  been  threatened  in  any  degree. 

Such  cases  are  not  always  so  fortunate.  Lives  that  looked  full  of 
promise  are  sometimes  blasted  on  the  threshold  of  what  seem  most  bril- 
liant careers,  as  in  the  following  case  of  K.  R.,  aet.  20.  Heredity  very 
neurotic,  mother  being  very  nervous,  aunt  insane,  and  father  drunken. 
He  had  been  a  most  brilliant  and  successful  student,  and  he  had  poetic 
gifts  that  made  his  friends  look  forward  for  his  future  with  much  enthu- 
siasm. His  illness  came  on  when  he  was  reading  hard,  sleeping  little, 
supporting  himself  by  teaching,  and  also  perhaps  further  exhausting  his 
energy  by  illicit  sexual  indulgence.  Without  any  proximate  cause  he 
became  much  exalted  in  mind  and  much  excited,  sleepless,  and  fell  off"  his 
food.  The  common  remedy  of  enormous  doses  of  morphia  was  resorted 
to.  He  got  sleep,  but  was  no  better  for  it,  and  after  it  would  take  no 
food  whatever.  When  he  came  to  the  asylum  he  was  quite  incoherent, 
raving  about  religion  and  women.  His  tongue  and  lips  were  dry;  his 
temperature  99°  ;  pulse  144,  small  and  thready  ;  and  his  general  strength 
small,  though  his  maniacal  muscular  energy  was  great.  I  could  get  him 
to  take  no  food,  so  at  once  fed  him  with  the  stomach-pump.  He  had  to 
be  put  in  the  padded  room  at  night  on  account  of  his  delirious  violence, 
but  was  taken  out  each  day  into  the  fresh  air  by  three  good  attendants. 
He  began  to  take  his  food  after  a  few  days,  but  remained  acutely  excited 
for  a  fortnight.  Then  there  was  a  remission,  but  the  mania  came  on 
again,  as  indeed  it  did  all  through  his  case,  by  spurts.  In  about  three 
months  he  began  to  be  more  coherent,  and  wrote  some  poetry.  As  it 
illustrates  the  common  mixture  of  religious  and  sexual  emotion  in  this 
and  most  of  those  cases  very  graphically,  I  quote  some  of  it  here : 

A  SOLEMN  ANTHEM  IN  CELEBRATION  OF  THE 
NEW  JERUSALEM. 

O,  Rosaly,  my  warm  and  panting  girl, 

Just  image  to  youi-self  the  gates  of  pearl  I 

The  angels  sitting  in  illustrious  row, 

Kissing  their  hands  to  the  Holy  Ghost  below, 

That  glorious  unimagined  mystery, 

The  very  hot  and  lovely  Trinity, 

Afar  they  see  the  lake  of  crystal  shine. 

Filled  with  the  juice  of  maidens'  paps  divine. 

They  hear  the  sappy  sound  of  neighboring  love 

And  kisses,  sacred  as  the  brooding  dove. 

They  look  unto  the  Great  White  Throne  and  laugh. 

Christ  plies  the  Virgin  with  luxurious  chaff; 

Jehovah  feels  the  Queen  of  Sheba's  beauty, 

And  refers  to  the  loveliness  of  Judy. 

The  Devil  reads  the  Sermon  on  the  Mount, 

And  adds  a  little  on  his  own  account. 

And  so  they  sing  their  wicked  songs  together, 

While  God  in  anger  frowns  upon  the  weather. 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.         381 

His  bodily  health  and  strength  gradually  improved,  his  beard  and 
whiskers  sprouted  in  great  luxuriance,  but  his  mental  power  did  not 
return.  He  continued  to  write  poetry,  but  it  got  more  and  more  inco- 
herent. He  called  himself  at  times  "Jesus  Christ,  Prince  Algernon 
Swinburne,"  though  this  was  scarcely  a  fixed  delusion.  He  had  been  an 
intense  admirer  and  great  reader  of  Swinburne's  poems,  and,  as  in  the 
specimen  given  above,  all  his  insane  poems  were  influenced  by  the  rhythm 
and  by  the  ideas  of  that  author.  The  treatment  adopted  was  the  same  as 
in  the  previous  case,  but  to  no  avail  as  regards  his  recovery.  The  change 
to  another  asylum  was  tried,  but  did  not  rouse  him.  He  sunk  into 
dementia  in  about  two  years. 

The  following  patient  was  not  a  head-worker :  K.  S.,  aet.  21.  A 
quiet,  steady,  and  intelligent  fisherman ;  stout,  ruddy,  and  strong  in 
body.  He  came  of  one  of  the  families  of  the  fishing  village  of  Newhaven, 
that  have  intermarried  for  many  generations,  and  in  many  of  which  now 
there  is  an  enormous  amount  of  insanity  or  epilepsy.  I  know  one  such 
family  where  four  girls  in  succession,  cousins  of  K.  S.,  became  subject  to 
epilepsy  and  then  became  insane.  If  any  proof  were  needed  of  the 
supreme  importance  of  hereditary  influences  in  the  production  of  mental 
diseases  and  epilepsy,  and  the  small  influence  of  healthy  conditions 
of  life  in  counteracting  these  hereditary  influences  in  many  instances,  I 
would  point  to  the  village  of  Newhaven.  Thd  people  are  well-fed  fisher 
folks.  They  are  robust  and  handsome.  Most  of  the  "bonny  fishwives" 
that  are  so  picturesque  an  element  in  the  street  scenes  and  street  sounds 
of  Edinburgh  belong  to  this  village.  The  life  they  lead  is  a  natural  out- 
door one,  and  yet  insanity  is  more  common  among  them  than  in  any 
community  of  a  similar  size  I  know.  That  fact  along  with  others,  noto- 
riously the  frequency  of  insanity  among  the  old  families  of  the  Society  of 
Friends,  the  most  self-controlled  and  virtuous  of  all  religious  sects,  is  a 
complete  answer  to  those  who  say  that  mental  diseases  are  mostly  due  to 
drink  and  vice  and  the  manifestly  bad  and  unnatural  conditions  of  modern 
town  life.  But  to  return  to  K.  S.  He  at  first  behaved  as  if  something 
was  "preying  on  his  mind,"  and  when  questioned  could  only  assign  as  a 
cause  a  common  dispute  in  a  boat.  This  was,  no  doubt,  the  melancholic 
prelude  to  the  attack.  Then  he  became  elevated,  and  then  maniacal  and 
violent.  This  lasted  for  about  a  week,  and  he  appeared  to  be  well.  In 
a  few  weeks  he  again  became  maniacal,  and  was  sent  to  the  asylum.  His 
bodily  health  seemed  absolutely  perfect  in  all  respects.  He  was  a  fine, 
fresh,  ruddy  young  son  of  the  sea.  He  was  set  to  hard  work  in  the  gar- 
den, and  in  ten  days  became  rational  and  quiet,  and  he  has  never  had 
another  attack  for  now  three  years.  I  noticed  that  during  three  months 
he  was  in  the  asylum  his  beard  and  whiskers,  which  were  nascent  on 
admission,  grew  out  full  and  strong,  so  that,  though  he  came  in  smooth- 
faced, he  left  a  bearded  man.  This  was  a  case  in  which  there  seemed 
absolutely  no  exciting  cause  whatever  for  the  attack  but  the  completion 
of  the  period  of  adolescence. 

The  following  case  was  one  that  made  a  complete  and  permanent 
recovery  after  being  over  a  year  very  ill  indeed :  K.  T.,  aet.  22. 
Mother  had  had  puerperal  mania.  At  eighteen  he  had  an  attack  of 
acute  mania,  which  lasted  for  two  months,  and  was  treated  at  home. 


882         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

Since  then  he  has  kept  well,  and  followed  an  outdoor  occupation,  till  his 
present  attack.  Before  coming  to  the  asylum  he  had  become  maniacal 
again  and  most  violent,  the  attack  beginning  with  elevation,  talkativeness, 
imprudent  conduct,  disrespect  to  his  father,  and  generally  such  behavior 
as  looked  like  mere  badness.  Many  such  cases  that  never  reach  the 
acutely  maniacal  stage  are  put  down  to  vice  and  drunkenness.  He  was 
sent  to  the  country  with  an  attendant,  and  seemed  to  recover  in  a  fort- 
night. He  then  returned  home,  but  in  a  month  from  the  beginning  of 
the  second  attack  he  became  maniacal  again,  and  was  sent  to  the  asylum. 
While  there  he  had  five  violent  attacks  of  acute  mania,  at  pretty  regular 
intervals  over  twelve  months,  and  then  recovered.  One  of  these  attacks 
was  longer  than  the  rest,  and  was  attended  with  considerable  emaciation, 
dirty  habits,  and  demented  expression  of  face,  and  I  was  afraid  of 
dementia,  but  the  treatment  I  have  described  Avas  most  energetically  per- 
sisted in,  and  he  recovered.  It  is  a  very  interesting  study  to  watch  such 
a  case  from  day  to  day  and  week  to  week,  I  consider  that  if  the  daily 
loss  of  flesh,  which  will  occur  for  perhaps  the  first  few  weeks  and  during 
the  acute  and  sleepless  stage,  is  checked  soon,  and  the  patient  ceases  to 
lose  weight,  that  it  is  a  good  sign.  I  encourage  the  attendants  to  feel  in 
those  cases  that  they  are  fighting  the  disease  with  milk  and  eggs  and  fresh 
air,  and  to  interest  them  in  the  case  by  letting  them  weigh  their  patients 
every  few  days.  A  good  attendant  will  show  a  lively  interest  in  the 
contest  with  the  disease,  and  will  feel  a  sense  of  personal  elation  or  defeat 
as  weight  is  gained  or  lost.  After  dementia  has  set  in,  body  weight  may 
be  gained  with  no  corresponding  mental  improvement ;  but  a  gain  in 
weight  within  the  first  six  months,  or  even  the  first  year,  means  that 
recovery  is  probably  going  to  take  place  ;  and  within  that  time  everything 
that  tends  towards  increased  body  weight  tends  towards  recovery. 

The  last  case  I  shall  refer  to  is  one  where  recovery  did  not  take  place, 
but  dementia  resulted.  K.  Y.,  aet.  16.  Has  an  aunt  in  the  asylum. 
Had  been  a  month  ill  before  admission.  He  was  excited,  noisy,  shouting, 
and  dancing  about.  That  was  in  1878.  For  four  years  he  was  subject 
to  attacks  of  acute  maniacal  excitement  at  intervals  of  a  few  months.  In 
the  first  year  they  were  very  acute.  This  is  a  general  rule.  My  expe- 
rience is  that  the  first  attack  or  the  second  is  apt  to  be  the  worst.  In 
K.  V.'s  case  the  attacks  got  less  acute  after  the  first  year,  but  in  the  in- 
tervals between  the  attacks  he  was  less  sane.  A  clouding  process  over 
his  mind  went  on,  each  attack  leaving  him  rather  more  enfeebled  than  the 
last.  But  he  was  once  so  well  that  he  was  tried  at  home  for  a  short  time. 
He  gradually  sunk  into  secondary  dementia,  with  rare  and  occasional 
spurts  of  restlessness  and  mild  maniacal  excitement  at  irregular  intervals 
— a  type  of  the  healthy  chronic  lunatic  that  forms  half  the  population  of 
most  asylums,  and  he  is  likely  to  live  for  many  years.  He  can  work  in 
the  garden,  can  answer  questions,  sleeps  well,  is  not  uncleanly  in  his 
habits,  mingles  in  the  asylum  amusements,  but  all  his  "higher  nature" 
is  gone.  He  cares  little  for  his  relations.  His  joys  and  sorrows  are 
very  mild.  He  has  no  interest  in  life,  no  ambition,  no  great  sense 
of  right  or  wrong,  no  volition  in  any  higher  sense,  and  no  religious 
instinct. 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.         383 

Treatmejjt  of  THE  INSANITY  OF  ADOLESCENCE. — The  treatment  I 
have  lately  adopted  for  such  cases  is  founded  on  physiological  considera- 
tions. The  completion  of  the  period  of  adolescence  is  in  both  sexes 
accompanied  by  a  considerable  deposit  of  adipose  tissue,  by  an  overplus 
of  strength  and  activity,  and  by  a  state  of  general  good  nourishment  of 
the  body.  To  attain  to  this  normal  condition  of  body  should  undoubtedly 
be  our  aim  in  treating  all  cases  of  mental  disease  at  this  period.  It 
always  seemed  to  me  that  there  were  two  things  that  constantly  Avorked 
the  other  way,  and  that  I  had  to  contend  against  in  their  treatment. 
These  were  the  general  brain  excitability  and  the  morbid  strength,  and 
often  perversion,  of  the  generative  nisus.  The  one  tended  to  mania, 
sleeplessness,  purposeless  motor  action,  thinness,  and  exhaustion ;  the 
other  to  erotic  trains  of  thought,  sexual  excitement,  and  masturbation. 
I  found  that  inaction,  reading,  indoor  life  and  amusements  increased  the 
one,  and  novel-reading,  solitariness,  and  long  hours  in  bed  aggravated 
the  other,  while  animal  food  and  alcoholic  stimulants  gave  increased 
strength  to  both  morbid  tendencies.  I  therefore  put  my  patients  to 
active  exercise  in  the  open  air  for  as  many  hours  a  day  as  possible, 
walking,  digging  in  the  garden,  wheeling  barrows ;  I  give  them  shower- 
baths  in  the  morning  when  the  weather  is  suitable  and  they  are  strong 
enough,  and  I  encourage  active  muscular  exercise  in  every  way.  Athletic 
games  of  all  sorts  in  the  open  air  are  certainly  good  so  far  as  they  go.  I 
place  great  reliance  on  the  diet.  Milk  in  large  quantity,  and  as  often  in 
the  day  as  possible,  bread,  porridge,  and  broth  are  the  staple  articles  of 
food  for  such  patients  here.  My  friend  Dr.  Keith,  of  this  city,  was  the 
first  to  direct  my  attention  to  the  advantage  of  a  light,  farinaceous,  and 
milk  diet  in  another  class  of  cases,  and  my  experience  is  strongly  in 
favor  of  his  views.  The  patients  may  have  some  fish,  or  fowl,  or  eggs, 
but  in  reality  milk  is  the  most  important  means  of  treatment.  I  seldom 
give  such  cases  alcoholic  stimulants.  I  give  to  all  such  patients  who  can 
take  and  assimilate  it  easily  an  emulsion  of  cod-liver  oil,  hypophosphite 
of  lime,  and  pepsine,  made  and  flavored  in  such  a  way  that  it  resembles 
cream.  I  find  very  few  indeed  who  cannot  take  this.  Beyond  this,  an 
occasional  bitter  tonic,  with  sometimes  a  chalybeate  or  some  of  the  new 
compound  syrups  of  the  phosphates,  are  about  all  the  medicines  I  give. 
The  efiect  of  this  diet,  regimen,  and  treatment  is  very  marked  in  the 
majority  of  cases.  No  doubt  during  the  first  part  of  the  attack  the 
patients  may  lose  weight  while  the  excitement  is  in  its  most  acute  stage ; 
but  they  soon  begin  to  gain  weight,  and  my  prognosis  is  always  favorable 
when  I  find  a  patient  beginning  to  gain  weight  within  a  reasonable  time, 
say  six  months  or  so.  I  have  had  patients  who,  in  spite  of  very  sharp 
excitement  indeed  and  much  sleeplessness,  gained  weight  under  this  treat- 
ment. It  seems  to  me  that  the  process  of  fattening  such  a  patient,  and 
the  conditions  under  which  it  takes  place,  are  antagonistic  to  the  disease 
and  its  results.  I  have  known  the  stopping  of  the  cod-liver  oil  to  be 
followed  at  once  by  a  loss  or  diminished  gain  in  weight,  and  its  resump- 
tion to  be  followed  by  the  former  rate  of  increase.  If  a  young  man  or 
woman  suffering  under  the  insanity  of  adolescence  is  found  to  gain  one 
or  two  pounds  a  week  within  the  first  three  months,  I  look  on  him  as  quite 
safe.     It  is  common  to  gain  a  stone  in  a  month. 


384         INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

I  have  now  pursued  this  plan  of  treatment  long  enough  to  yield  results 
that  can  be  relied  on,  and  I  believe  that  more  of  my  patients  recover  than 
before  I  adopted  it.  They  recover  sooner,  and  their  recoveries  are  more 
reliable  and  permanent.  Even  in  the  case  of  those  who  sink  into  de- 
mentia, I  think  they  do  so  more  quietly  and  with  less  of  the  element  of 
chronic  mania  than  under  a  flesh  diet.  It  is,  I  think,  certain  that  the 
habit  of  masturbation,  which  is  so  frequent  and  so  deleterious  in  such 
cases,  is  less  practised  by  patients  on  this  diet,  and,  when  practised,  is 
less  damaging  to  brain  function,  and  takes  less  hold  on  them. 

Lastly,  in  connection  with  this  subject,  I  would  say  a  word  about  pro- 
phylaxis in  children  with  a  strong  neurotic  inheritance.  My  experience 
is  that  the  children  Avho  have  the  most  neui'otic  temperaments  and  dia- 
theses, and  who  show  the  greatest  tendencies  to  instability  of  brain,  are, 
as  a  rule,  flesh-eaters,  having  a  craving  for  animal  food  too  often  and  in 
too  great  quantities.  I  have  found  also  a  large  proportion  of  the  adoles- 
cent insane  had  been  flesh-eaters,  consuming  and  having  a  craving  for 
much  animal  food.  It  is  in  such  boys  that  the  habit  of  masturbation  is 
most  apt  to  be  acquired,  and,  when  acquired,  produces  such  a  fascination 
and  a  craving  that  it  may  ruin  the  bodily  and  mental  powers.  I  have 
seen  a  change  of  diet  to  milk,  fish,  and  farinaceous  food  produce  a  marked 
improvement  in  regard  to  the  nervous  irritability  of  such  children.  And 
in  such  children  I  thoroughly  agree  with  Dr.  Keith,  who  in  Edinburgh 
for  many  years  has  preached  an  anti-flesh  crusade  in  the  bringing  up  of 
children  up  to  eight  or  ten  years  of  age.  I  believe  that  by  a  proper  diet 
and  regimen,  more  than  in  any  other  way,  we  can  fight  against  and 
counteract  inherited  neurotic  tendencies  in  children,  and  tide  them  safely 
over  the  periods  of  puberty  and  adolescence. 

The  following  is  a  statistical  and  clinical  inquiry  into  the  subject  of  the 
insanity  of  adolescence.  For  this  inquiry  I  took  for  the  period  of  five 
years  and  a  quarter  (from  1874  till  the  end  of  the  first  quarter  of  1879) 
all  the  cases  that  were  admitted  into  the  Royal  Edinburgh  Asylum. 
They  amounted  to  1796 — 917  men  and  879  women.  Of  these,  320 
were  between  the  ages  of  14  and  25,  viz. :  195  males  and  125  females. 
Now,  if  my  object  had  merely  been  to  arrange  those  320  patients  each 
in  a  classification  of  symptoms,  it  would  have  been  simple  enough :  so 
many  with  exaltation  under  "Mania,"  so  many  with  depression  under 
"Melancholia,"  etc.  That  was  done,  but  a  great  deal  more  informa- 
tion must  be  expiscated  about  each  case  if  we  are  to  arrange  them  in 
clinical  or  physiological  groups,  and  especially  if  we  are  to  have  any 
light  thrown  on  the  question — "  Did  adolescence  influence  the  mental 
symptoms  present  in  those  cases?"  We  must  ask  and  answer  the  fol- 
lowing inquiries  :  "  In  how  many  cases  did  the  disease  exist  before  the 
age  of  14,  or  was  of  a  kind  with  which  adolescence  could  have  nothing  to 
do  ?"  I  found  I  had  to  deduct  90  such  cases,  or  about  one-third  of  the 
320  who  had  been  mentally  defective  or  epileptic  from  birth,  or  very 
early  ages,  or  labored  under  organic  disease,  or  in  whom  the  disease 
came  on  in  nursing  or  childbirth,  leaving  230  in  whom  it  was  possible 
for  puberty  or  adolescence  to  cause  or  influence  the  disease. 

The  next  inquiry  naturally  was — "  If  230  occurred  in  the  twelve  years 
between  the  ages  of  14  and  25,  is  that  number  greater  or  less  than  is 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.  385 

found  in  the  same  number  of  years  at  other  ages?"  I  find  it  to  be  far 
more  than  between  2  and  14,  but  less  (10  per  cent.)  than  between  30 
and  40.  At  this  particular  age,  either  from  adolescence  or  some  other 
cause,  it  is  clear  that  there  arises  a  liability  to  insanity  which  did  not 
before  exist,  but  which  does  not  cease  when  adolescence  is  past. 

The  next  query  was  this :  "  Taking  this  long  period  of  twelve  years, 
is  there  any  special  liability  during  any  of  the  years  of  that  time?" 
"  Does  it  arise  at  puberty,  or  towards  the  completion  of  the  period  of 
adolescence?"  A  glance  at  the  numbers  who  became  insane  in  each  of 
the  twelve  years  shows  that  the  first  two,  that  is  the  14th  and  15th,  were 
especially  exempt,  only  producing  one  case  each  ;  and  the  next  two,  the 
16th  and  17th,  also  very  few  (22).  Now  the  fact  that  there  only  occurred 
in  those  four  years  of  life  24  cases  out  of  about  1800  in  all  (230  of  them 
being  adolescents  and  healthy  up  to  that  period),  does  show  clearly  that 
the  first  onset  of  the  reproductive  function  is  not  a  dangerous  one  as  re- 
gards liability  to  insanity. 

The  next  three — the  18th,  19th,  and  20th — are  still  low,  producing 
only  49  cases,  or  an  average  of  16  in  each  year.  In  those  three  years, 
while  puberty  has  occurred  in  nearly  every  individual  of  both  sexes,  yet 
adolescence  has  not  been  completed  in  many  of  them. 

It  was  in  the  next  five  years,  from  the  21st  to  the  25th,  that  the  vast 
majority  of  the  cases  occurred,'  viz. :  157  of  the  230,  or  an  average  of  31 
in  each  year  as  compared  with  an  average  of  8  for  each  of  the  first  five 
years.  At  14  and  15  the  liability  to  insanity  was  practically  nil,  from 
21  to  25  it  was  very  great.  In  fact,  a  comparison  with  the  liability  at 
other  ages  during  the  past  five  years  in  the  admissions  to  the  asylum 
shows  that  there  is  no  period  of  life  in  which  uncomj)licated  insanity  occurs 
more  frequently  than  during  the  completion  of  the  physiological  era  of 
adolescence,  from  21  to  25.  It  must  be  kept  in  mind  that  I  am  not  now 
speaking  of  the  numbers  becoming  insane  in  proportion  to  the  number  of 
the  general  population  alive  at  any  particular  period. 

Comparing  the  two  sexes,  the  total  numbers  and  relative  proportion  of 
females  are  smaller  in  the  adolescent  period  than  at  later  periods  of  life. 
Adolescence  does  not  appear  "to  be  so  powerful  an  upsetter  of  mental 
equilibrium  in  women  as  in  men. 

Having  elucidated  these  points,  we  come  to  the  question  as  to  what 
mental  symptoms  these  adolescents  suffered  from,  and  if  those  symptoms 
were  in  any  way  peculiar  ?  While  investigating  this,  I  found  the  com- 
plications of  marriage,  childbearing,  and  lactation  in  the  females  so 
common  after  the  age  of  21,  that  it  was  difficult  to  compare  them  with  the 
males.  I  therefore  made  21  the  limit  of  age  for  them.  This  reduced 
their  numbers  to  40,  making,  with  the  140  males,  180. 

The  first  fact  of  importance  is,  that  there  were  only  40  cases  in  which 
the  symptoms  present  were  classed  as  states  of  mental  depression  or 
melancholia,  while  the  rest  were  cases  of  exaltation  or  mania.  Now,  the 
significance  of  this  proportion  is  only  seen  by  comparison.  During  the 
past  five  years  in  the  asylum  there  have  been  admitted  two  cases  of  un- 
complicated mania  to  one  of  melancholia  (849  to  439),  whereas  among 
the  adolescents  it  was  3J  to  1  (140  to  40).  And  if  we  compare  them 
with  those  at  more  advanced  ages,  e.g.,  women  at  the  climacteric  period, 

25 


386  INSANITIES    OF    PUBERTY    AND    ADOLESCENCE. 

the  proportion  of  mania  to  melancholia  is  reversed,  there  being  only  one 
case  of  the  former  to  If  of  the  latter. 

The  proportion  of  states  of  exaltation  of  mind  or  mania,  therefore,  is 
much  greater  as  compared  with  those  of  melancholia  among  the  adolescent 
insane  than  among  the  insane  at  all  ages,  this  excess  being  still  more 
marked  when  compared  with  the  cases  of  mental  disease  occurring  at  the 
climacteric  period  of  life. 

The  next  inquiry  was — "  What  was  the  character  of  the  mania?"'  I 
found  that  it  had  several  well-marked  characteristics.  It  was,  in  the  first 
place,  often  of  a  very  acute,  though  seldom  of  a  delirious  type ;  in  the 
second  place,  it  was  mostly  of  short  duration,  the  patients  getting  soon 
apparently  quite  well ;  in  the  third  place,  the  patients  were  subject  to 
constant  relapses.  Out  of  the  180  cases,  118,  or  66  per  cent.,  had  such 
intermissions  of  sanity  with  subsequent  relapses.  This  tendency  to  short, 
sharp  attacks,  with  intermissions  of  more  perfect  sanity  than  occurs  in 
most  other  kinds  of  mental  disease,  with  relapses  occurring  one,  two, 
three,  four,  and  five  times,  and  even  more  frequently,  before  recovery  or 
dementia  finally  takes  place,  may  be  taken  to  be  especially  characteristic 
of  this  insanity  of  adolescence.  In  many  of  them,  as  the  maniacal  attacks 
passed  off,  there  was  a  slight  tendency  to  melancholia,  a  sort  of  reaction 
no  doubt.  This  was  noticed  in  62  cases.  This  relapsing  character  with 
the  tendency  towards  depression  brings  adolescent  insanity  into  relation- 
ship with  folie  circulaire.  The  real  cause  of  the  remissional  character 
of  both  is  no  doubt  the  periodicity  of  the  generative  power  and  desire  in 
their  greatest  intensity. 

Another  well-marked  characteristic  was  this,  that  a  hereditary  predis- 
position to  mental  disease,  or  at  least  to  some  of  the  neuroses,  was  present 
in  77  of  the  180,  or  in  45  per  cent,  of  the  whole  number.  It  is  very 
diflBcult  to  get  family  histories  of  insanity  in  most  cases,  and  you  may 
multiply  by  two  those  you  get,  if  you  want  an  approach  to  the  truth. 
The  proportion  of  hereditary  predisposition  in  the  asylum,  as  recorded  in 
our  case-books,  is  only  23  per  cent,  as  compared  with  the  45  per  cent, 
among  the  adolescents,  in  whose  cases  no  special  pains  had  been  taken 
to  ascertain  family  histories.  I  observed  a  still  more  striking  fact  in 
regard  to  the  heredity  of  the  insanity  of  adolescents.  I  happened  to 
have  a  personal  knowledge  of  the  history  of  the  cases  or  of  the  families  in 
fifteen  of  the  cases,  and  in  twelve  of  these  there  was  a  hereditary  predis- 
position to  the  neuroses.  The  insanity  of  adolescence  is  therefore  pre- 
disposed to  in  most  cases  by  a  nervous  heredity,  being  one  of  the  most 
hereditary  of  all  forms  of  mental  disease. 

Another  marked  character  of  the  mania  was  that  the  ideas,  emotions, 
speech,  and  conduct  were  all  strongly  tinctured  by  the  mental  charac- 
teristics of  adolescence  in  an  exaggerated  or  morbid  way.  That  per- 
version of  the  sexual  act,  the  habit  of  masturbation,  was  very  common, 
probably  existing  in  over  50  per  cent,  of  the  cases,  aggravating  the 
symptoms,  and  diminishing  the  chances  of  recovery.  In  the  females 
hysterical  symptoms  were  common,  such  as  mock  modesty,  simulated 
pains,  and  a  desire  to  attract  attention.  In  the  males  heroic  notions,  an 
imitation  of  manly  airs  and  manners,  an  obstrusive  pugnaciousness,  and 
sometimes  a  morbid  sentimentality  were  present.     In  almost  all  the  cases 


INSANITIES    OF    PUBERTY    AND    ADOLESCENCE.  887 

the  physical  appearance  of  the  males  was  boyish  when  the  attack  com- 
menced ;  and  most  of  the  females  were  girlish  rather  than  womanly  in 
contour. 

As  regards  the  results  of  treatment  in  those  cases,  93  were  discharged 
recovered,  or  51  per  cent. ;  but  then  40  were  removed  home  or  to  other 
institutions  relieved,  many  of  whom  would  have  been  likely  to  recover 
ultimately.  I  only  know  of  26  of  the  180  who  became  incurable.  In- 
sanity occurring  at  the  adolescent  period  is,  therefore,  a  very  curable 
disorder,  as  compared  with  many  other  forms,  though  not  so  curable  as 
some  others,  e.  g.,  puerperal  insanity.  Just  before  recovery,  in  almost 
all  the  cases  which  did  get  well,  signs  of  physiological  manhood  appeared, 
the  beard  growing,  the  form  expanding,  the  weight  increasing.  When- 
ever I  see  those  signs,  accompanied  by  mental  improvement,  I  am  in- 
clined to  give  a  favorable  prognosis.  The  mortality  was  very  low,  only 
three  of  the  180  cases  having  died. 


LECTURE    XVII. 

CLIMACTEKIC  INSANITY— SENILE  INSANITY. 

As  unstable  brains  are  apt  in  certain  cases  to  be  upset  in  their  mental 
functions  by  the  oncoming  of  the  reproductive  power  and  the  sexual 
desire  at  the  periods  of  puberty  and  adolescence,  so  they  are  apt  to  suffer 
as  those  great  powers  of  the  organism  pass  away  at  the  climacteric  period. 
An  animal  has  functionally  and  physiologically  three  distinct  periods  of 
existence — (1)  when  its  life  is  dependent  on  that  of  its  mother  before 
birth ;  (2)  when  it  lives  independently,  but  cannot  reproduce  itself,  before 
puberty  and  after  the  climacteric ;  and  (3)  when  it  both  lives  and  can 
reproduce.  The  mental  function  is  non-existent  in  the  first  period,  more 
or  less  imperfect  in  the  second,  and  fiilly  developed  in  an  ideal  sense  only 
in  the  third.  At  the  period  of  the  climacteric  there  is  unquestionably  a 
normal  mental  change  in  both  sexes.  The  sexual  desire  invariably 
weakens  in  its  intensity  or  ceases  altogether,  and  with  it  the  affectiveness 
changes  in  its  object  and  greatest  intensity  from  the  mate  to  the  progeny, 
losing  its  imaginative  force,  its  fire,  and  its  impulsiveness.  Poetry  and 
love  tales  then  cease  to  have  the  power  "  to  set  the  brain  on  fire." 
Action  of  all  kinds  ceases  to  be  so  pleasurable  for  its  own  sake  as  it  has 
been  before.  Much  of  "the  go  is  out"  of  the  person.  The  instinctive 
feeling  of  difference  of  sex,  and  all  that  it  implies,  which  has  been  all- 
pervading  before,  now  lessens  visibly.  The  subtle  interest  of  the  society 
of  the  other  sex  is  less  electric  and  overmastering.  Along  with  these 
affective  changes  there  are  bodily  changes  too.  The  form  alters,  especially 
in  women,  and  the  expression  of  face  changes,  the  ovaries  shrivel,  Peyer's 
patches  lessen  in  bulk,  and  the  spleen  and  lymphatic  glands  harden. 
The  blood-forming  and  the  blood-using  processes  slacken  in  speed,  and 
the  trophic  energy  in  all  the  tissues  is  less  intense  in  action.  "Life 
becomes  slower,"  in  fact,  mentally  and  physically.  And  as  a  result  of 
this,  after  the  climacteric  has  been  safely  passed,  the  organism  is  less 
liable  to  many  diseases  than  it  has  been  before.  The  real  climacteric 
period  in  both  sexes  is  never  a  definite  fixed  time,  but  usually  extends 
over  a  year,  or  two,  or  three.  The  mere  cessation  of  the  function  of 
menstruation  in  women  does  not  necessarily  fix  definitely  the  mental  and 
nutritional  changes  that  mark  the  period.  I  have  known  a  woman  of 
fifty  who  had  gone  through  the  mental  changes  of  the  climacteric,  yet  in 
facial  expression  and  in  shape  was  post-climacteric,  who  had  no  sexual 
desire,  yet  was  menstruating  regularly ;  and,  on  the  other  hand,  I  have 
known  many  women  of  the  same  age  in  whom  menstruation  had  ceased 
fi"om  forty  to  forty-six,  who  were  yet  quite  shapely,  amorous,  and  men- 
tally youthful.  So  the  mental  disease  that  accompanies  the  climacteric 
need  not  be  quite  coincident  with  the  menopause,  but  may  occur  some 


CLIMACTERIC    INSANITY.  389 

time  before  or  some  time  after  that  event.  As  a  matter  of  fact,  the 
ordinary  sensory  nervous  symptoms  that  are  connected  witli  the  climac- 
teric in  women,  viz.,  giddiness,  flushings,  flashes  of  light,  uneasy  organic 
sensations,  usually  precede  the  actual  cessation  of  the  menses  rather  than 
accompany  it. 

A  typical  case  of  climacteric  insanity  begins  by  a  loss  of  energizing 
power,  bodily  and  mentally,  of  which  the  patient  is  rather  supersensi- 
tively  conscious.  Her  courage  fails ;  little  things  come  to  have  the 
power  of  annoying  her  that  she  would  have  thought  nothing  of  before. 
Groundless  fears,  which  at  first  she  knows  to  be  groundless,  haunt  her  at 
times.  And  at  this  stage  the  sleep  is  apt  to  be  dreamy  and  broken,  the 
appetite  for  food  is  less  intense,  and  the  bowels  costive.  There  is  apt  to 
be  some  falling  off"  in  freshness  of  the  complexion  and  in  looks  generally. 
The  skin  often  gets  muddy,  and  more  pigmented  than  usual.  It  is  a 
trouble  for  her  to  go  into  company  or  to  move  about  in  public,  and  yet 
she  has  no  restful  feeling  and  no  contentment  or  organic  happiness.  At 
the  menstrual  times  all  these  things  are  much  worse,  and  there  is  apt  to 
be  real  depression  of  mind,  weeping,  with  irritability  of  temper  and 
sleeplessness.  I  have  never  yet  met  with  a  climacteric  case  in  this  early 
stage  who  did  not  feel  much  better  in  the  open  air  than  in  the  house. 
That  is  an  indication  of  treatment  and  of  prevention  of  further  symptoms 
that  I  never  fail  to  find  useful.  I  have  seen  iron  at  this  stage,  too,  do 
very  much  good;  in  fact,  it  seemed  to  act  as  a  specific.  But  those  symp- 
toms do  not  constitute  insanity,  though  they  are  essentially  mental  dis- 
order. 

The  next  stage  consists  of  more  real  and  continuous  depression.  The 
morbid  fears  assume  a  more  intense  character,  though  they  are  often  still 
indefinite.  The  patient  is  quite  sure  some  evil  thing  is  going  to  happen 
to  her,  though  she  cannot  tell  what  it  is  to  be.  The  self-control  is  often 
lost,  but  much  more  frequently  the  patient  is  terrified  that  it  is  going  to 
be  lost.  There  are  vague  impulses  towards  suicide,  sometimes  towards 
hurting  husband  and  children,  and  the  existence  of  these  add  to  the  terror 
and  intensify  the  depression.  Such  things  are  thought  by  the  patient  to 
be  ''so  wrong,"  and  she  blames  herself  for  them.  A  conscious  loss  of 
affection,  or  rather  a  loss  of  the  pleasurable  feeling  that  conscious  affec- 
tion for  husband  and  children  gives,  is  a  cause  of  the  greatest  distress. 
There  is  often  a  sort  of  organic  repugnance  to  the  husband  and  to  his 
attentions.  By  this  time  all  the  usual  sensory  accompaniments  of  the 
climacteric  have  disappeared,  or  rather  they  have  been  transformed  into 
the  mental  neurosis  I  am  describing.  There  are  no  headaches,  or  giddi- 
ness, or  flushings.  But  the  trophic  neuroses  become  aggravated  all  the 
time.  The  thinness,  the  flabbiness  of  muscle,  the  pigmentation  of  skin, 
get  worse.  There  are*  frequently  skin  irritations,  and  the  patient  picks 
and  scratches  her  skin.  The  bowels  are  costive,  the  appetite  gone,  the 
sleep  absent,  and  the  capacity  for  work  greatly  lessened. 

In  the  worst  cases,  suicidal  feelings  are  strong  and  attempts  frequent, 
but  they  are  rather  apt  to  be  feeble.  The  vei*y  loss  of  courage  and  vigor 
of  will  operates  against  any  effectual  attempts  at  suicide,  however  much 
the  wish  may  be  there.  Hallucinations  of  hearing  are  frequent.  This 
condition  may  pass  into  acute  excited  melancholia  and  exhaustion,  and 


390  CLIMACTERIC    INSANITY. 

death  ensue,  or  it  may  become  a  sort  of  chronic  shy  uselessness,  or 
"paralysis  of  energy,"  or  it  may  gradually  pass  away  under  proper 
treatment  and  conditions  of  life,  and  the  woman  become  strong,  cheerful, 
well-nourished,  and  useful,  more  "healthy"  in  a  certain  sense  at  all 
events  than  ever. 

The  following  is  a  case  of  climacteric  insanity,  of  short  duration  but 
very  acute  form,  and  with  an  element  of  stupor. 

K.  v.,  set.  46,  of  a  cheerful  and  sociable  disposition,  and  good  habits, 
but  with  some  heredity  to  insanity  and  the  neuroses,  a  sister  having  been 
insane,  and  a  child  having  died  of  hydrocephalus.  My  impression  is 
that,  of  all  the  expressions  of  an  heredity  to  insanity  in  childhood, 
hydrocephalus  is,  next  to  convulsions,  the  most  common.  The  whole 
question  of  the  transmission  of  neuroses  to  children  by  mothers  who  are 
then  to  all  appearance  healthy,  and  in  whom  any  nervous  disease  is  a 
mere  potentiality,  is  very  interesting,  and  stands  in  need  of  accurate 
observations.  The  weak  and  troublesome  point  of  all  studies  of  heredity 
is  that  they  cannot  be  regarded  as  complete  till  all  the  subjects  of  them 
are  dead.  K.  V.  had  over-exertion  of  body  and  anxiety  of  mind  in 
nursing  her  husband  and  through  his  death,  just  as  she  was  becoming 
irregular,  this  being  the  exciting  cause  of  her  attack.  She  became  irreg- 
ular in  her  menstruation,  but  had  not  many  of  the  usual  sensoiy  accom- 
paniments of  the  climacteric.  My  experience  is  that  in  the  climacteric 
cases  with  a  mental  neurosis,  the  former  are  often  enough  absent.  The 
one  seems  to  come  instead  of  the  other.  She  never  slept  well  after  her 
husband's  death.  In  about  two  months  thereafter  she  became  depressed, 
and  suspicious  that  her  neighbors  had  an  ill-will  to  her  and  that  everyone 
was  against  her.  It  is  easy  to  see  how  a  lone,  neurotic  widow,  with  a 
family  to  support,  should  take  such  ideas.  But  by  and  by  she  began  to 
fancy  that  her  friends  put  poison  in  her  food ;  no  doubt  this  was  the 
misjudged  sensation  of  the  pain  of  dyspepsia.  Then  she  began  to  groan 
most  of  the  time,  and  to  cease  to  attend  to  her  work,  or  to  take  an  interest 
in  anything,  her  whole  mind  being  absorbed  in  her  morbid  thoughts.  On 
being  sent  to  the  asylum,  she  picked  up  to  some  extent  at  once,  exercising 
all  the  self-control  she  was  capable  of,  the  very  unpalatableness  of  the 
situation  rousing  her.  She  was  thin  and  dark-skinned,  and  had  a  dull, 
listless  look.  Her  sensibility  to  pain  was  dulled,  there  being  an  element 
of  mental  stupor  in  her  case.  The  tongue  was  furred  and  tremulous,  and 
the  bowels  costive.  Her  pulse  was  88,  weak ;  her  temperature  99.3°  ; 
and  her  weight  only  eight  stone  eight  pounds.  She  was  much  depressed 
and  confused,  mistaking  the  identity  of  people  about  her.  She  slept 
very  little  at  first.  Her  appetite  was  poor,  and  her  notions  of  cleanliness 
and  decency  were  meagre.  She  was  ordered  quinine  and  iron,  warm 
baths,  exercise  in  the  fresh  air,  simple  laxatives,*and  proper  supervision 
and  nursing.  In  a  fortnight  she  was  sleeping  better,  in  a  month  she  was 
sleeping  well.  She  took  plenty  of  food,  occupied  herself  in  useful  work, 
and  her  skin  began  to  look  clearer  and  more  healthy.  Her  fears  and 
delusions  became  vague,  and  with  less  influence  on  her  demeanor.  She 
would  then  take  a  good  fit  of  crying,  which  did  her  good.  In  another 
month  she  had  gained  over  a  stone  in  weight,  and  was  fairly  convalescent, 
and  being  much  needed  at  home,  was  sent  there  perhaps  earlier  than 


CLIMACTERIC    INSANITY.  391 

might  otherwise  have  been  desirable.  The  disease  in  such  short  cases 
has  little  tendency  to  recur.  When  she  left  she  was  getting  the  post- 
climacteric look. 

The  following  case  is  one  in  which  the  symptoms  of  climacteric  insanity 
came  on  several  years  after  the  menopause,  were  never  very  acute,  yet 
the  woman  has  not  got  over  them  for  two  years.  She  is  rational  in 
conversation,  and  has  no  delusions,  and  her  depression  is  by  no  means 
acute,  but  she  is  so  absolutely  devoid  of  initiative  power  and  energy  that 
she  remains  voluntarily  in  the  asylum,  and  is  quite  unfit  to  do  her  work 
in  life.  K.  W.,  aet.  51,  a  widow,  a  healthy,  cheerfiil,  active  woman,  who 
had  two  children,  and  no  heredity  to  insanity.  About  forty-five,  so  far 
as  she  remembers,  she  ceased  to  menstruate,  this  being  accompanied  by 
fearful  headaches,  feeling  sometimes  as  if  she  would  "  go  out  of  her 
mind."  Those  headaches  continued  more  or  less  up  to  the  onset  of  her 
present  attack  of  melancholia,  but  she  did  not  change  in  facial  expression, 
and  did  not  lose  her  shape,  in  fact  did  not  exhibit  the  usual  bodily  signs 
of  having  passed  the  crisis,  till  the  depression  of  mind  began  to  appear. 
At  fifty-one,  without  any  cause,  she  became  depressed  in  mind,  nervous, 
anxious,  and  fearful.  She  gradually  developed  the  delusion  that  her 
friends  wished  to  take  her  life.  She  was  sleepless,  and  once  threatened 
to  throw  herself  out  of  the  window.  She  lost  all  hope  and  courage  and 
interest  in  life.  She  got  occasionally  excited  and  lost  her  self-control, 
which  was  the  cause  of  her  being  sent  to  the  asylum,  but  during  the  two 
years  she  has  been  there  she  never  has  shown  any  sign  of  excitement, 
except  on  one  occasion  slightly.  She  has  simply  been  a  dull,  anxious, 
retiring  person,  morbidly  fearful  of  giving  offence,  and  having  a  dread  on 
her  that  something  fearful  is  going  to  happen  to  her.  She  has  eaten  and 
slept  well.  She  does  what  she  is  told  without  interest.  She  has  vague 
semi-delusional  ideas  that  her  friends  are  all  dead,  that  the  people  here 
seem  to  be  the  same  as  her  former  friends,  that  the  things  and  people 
about  here  are  not  real.  She  has  those  feelings,  yet  she  does  not  really 
believe  them.  She  has  pains  and  numbnesses  in  her  joints  and  her  limbs, 
probably  neurotic  in  origin.  She  eats  well — far  more,  she  says,  than  she 
ever  did  before — looks  stout  and  well,  sleeps  w^ell,  and  is  muscularly  strong, 
though  not  alert  or  active.  She  leads  a  dependent  life,  with  no  joy  in  it 
at  all  or  no  interest  in  anything,  but  with  little  intellectual  impairment  in 
the  sense  of  dementia.  She  shows  no  sign  of  recovery  and  no  sign  of 
getting  worse.  Yet  I  think  recovery  perfectly  possible  in  her  case,  for 
I  have  seen  such  cases  recover  after  several  years.  She  lives  on  a  lower 
plane  emotionally,  and  as  to  energy  and  spontaneity.  She  never  laughs, 
but  never  cries,  and  never  loses  her  temper.  She  has  no  pleasure  in  social 
intercourse,  but  she  does  not  shun  her  fellows.  This  is  to  me  just  an  ex- 
aggerated and  morbid  type  of  post-climacteric  physiological  and  psycho- 
logical life. 

Some  of  the  cases  take  a  long  time  to  recover.  I  never  give  up  hope 
of  recovery  in  a  climacteric  case  for  four  or  five  years,  except  there  are 
symptoms  of  dementia  or  fixed  delusions.  The  physiological  period  of 
life  not  being  a  fixed  or  always  a  short  time,  therefore  its  morbid,  nervous, 
and  mental  accompaniments  are  often  prolonged  and  irregular. 

The  period  of  the  climacteric  in  the  male  sex  occurs  at  a  later  time  of 


392  CLIMACTERIC    INSANITY. 

life  than  in  the  female,  and  is  much  more  irregular  and  indefinite.  There 
is  nothing  to  mark  it  off  so  clearly  as  the  menopause.  Sexual  power  re- 
mains, but  the  appetite  for  it  is  not  in  normally  constituted  persons  keen 
or  pervading.  There  is  little  or  no  self-control  needed  to  restrain  it,  as 
in  earlier  years,  and  indeed  it  is  commonly  dormant,  except  when  stimu- 
lated. The  common  age  for  the  "grand  climacteric"  in  man  is  from 
fifty-five  to  sixty-five,  a  few  cases  occurring  before  and  after  those  ages. 
The  popular  tradition  puts  it  at  sixty-three.  The  procreative  power  of 
man  has  been  demonstrated  by  statistics  to  become  progressively  less 
after  fifty,  and  to  be  in  reality  small  at  the  latter  age.  The  normal 
mental  change  in  man  is  essentially  the  same  as  in  woman. 

The  abnormal  mental  changes  that  are  seen  in  some  cases  at  the 
climacteric  period  in  men  are  the  same  in  general  type,  too,  as  in  women. 
The  spontaneity,  the  courage,  the  mental  aggressiveness,  the  necessity  to 
energize  actively,  the  poetic  sentiment,  the  keenness  of  feeling  in  all  di- 
rections, all  these  are  impaired.  There  is  no  drawing  towards  the  other 
sex,  and  no  subtile  delight  in  its  presence.  The  sleep  is  less  sound  and 
shorter.  A  cloud  of  vague  depression  rests  on  the  man,  who  shuns 
society,  falls  off  in  fat,  becomes  restless  and  hypochondriacal,  and  feels 
strongly  the  tedium  vitce.  This  may  go  on  to  suicidal  longings  and 
desires,  which  are  usually  not  very  intense.  In  fact,  nothing  is  intense 
with  the  man.  His  energies,  his  functions,  and  his  vitality  have  all  been 
lowered.  With  this  there  is  no  atheroma,  areus  senilis,  or  proper  senility. 
The  following  was  an  aggravated  case  of  senile  insanity  in  the  male  sex : 
K.  X.,  aet.  56.  A  quiet  man,  of  melancholic  temperament,  steady  and 
industrious  in  his  habits,  and  with  no  known  heredity  to  insanity.  Lately 
he  had  little  work  and  not  much  food,  and  was  therefore  anxious  and 
underfed.  He  gradually  became  dull,  and  possessed  with  the  fear  that 
something  dreadful  was  going  to  happen  to  him  and  his  family — a  fear 
founded  on  realities  at  first,  but  gradually  assuming  a  delusional  character. 
He  became  taciturn  and  wearied  of  his  life,  ceased  to  take  any  interest  in 
anything,  and  could  not  be  roused.  One  morning,  just  before  coming 
into  the  asylum,  he  told  his  wife  to  get  up  at  once  and  conceal  herself, 
as  he  had  a  strong  desire  to  kill  her  and  others.  On  admission  he  said 
he  felt  very  badly,  that  strange  and  frightful  ideas  came  into  his  head 
and  preyed  on  his  mind.  One  minute  he  was  looking  the  picture  of 
misery  and  sitting  quite  still,  then  he  would  lose  control  over  himself 
and  become  restless  and  impulsive,  and  strike  and  bite  those  near  him. 
He  was  thin,  pale,  flabby  in  his  muscles,  and  his  skin  dark,  muddy,  and 
pigmented.  He  had  been  blistered  at  the  back  of  his  head  before  ad- 
mission (blisters  are  good  treatment  for  some  cases  of  insanity,  but  not 
for  a  half-starved,  melancholic  workman  at  the  climacteric).  He  had  a 
vague,  indefinite  dread  on  him,  and  an  absolute  lack  of  interest  in  any- 
thing in  life,  though  his  memory  and  general  intelligence  were  good. 
His  tongue  was  foul,  his  bowels  costive.  There  were  no  visible  signs  of 
atheroma  of  the  arteries.  He  took  his  food  fairly  well  at  first,  and  was 
ordered  extra  diet,  porter,  and  Parrish's  syrup  of  the  phosphates.  He 
improved  considerably  for  the  first  six  months  in  body  and  mind,  but  he 
never  got  to  enjoy  life  or  to  be  sociable.  After  that  time  he  got  worse, 
did  not  take  his  food  well,  and  fell  off  again  in  flesh.     Everything  was 


CLIMACTEEIC    INSANITY.  393 

done  to  improve  his  appetite,  and  nourishment,  quinine,  cod-liver  oil,  the 
phosphates  and  hypophosphates,  garden  work,  and  amusements  were  all 
tried,  hut  he  got  steadily  worse.  He  became  more  solitary  and  silent. 
His  blood  got  so  abnormal  that  at  one  time  purpuric  spots  appeared  over 
his  legs.  His  delusions  assumed  more  of  a  hypochondriacal  character 
before  his  death,  which  took  place  two  and  a  half  years  after  admission. 
He  thought  all  his  organs  Avere  diseased,  and  that  he  had  no  stomach. 
He  died  suddenly  at  last,  being  then  a  mere  skeleton  from  exhaustion. 
The  brain  convolutions  were  found  to  be  atrophied  and  very  anaemic  ;  the 
arteries  had  begun  to  show  the  atheromatous  degeneration ;  there  were 
some  granulations  on  the  floor  of  the  fourth  ventricle,  and  the  lateral  ven- 
tricles were  dilated  and  filled  with  a  pink  serum.  There  was  a  patch  of 
Avhite  softening,  about  the  size  of  a  filbert,  in  the  centre  of  the  left 
hemisphere.  The  aorta  was  markedly  atheromatous.  This  case  had  not 
had  during  life  any  of  the  distinctively  senile  mental  characters,  yet  the 
pathology  was  undoubtedly  like  that  of  many  senile  cases. 

Of  a  much  more  common  type  was  the  following  less  aggravated  case : 
K.  Y.,  aet.  57,  a  professional  man,  w^ho  had  worked  very  hard  indeed. 
He  had  a  slight  and  distant  heredity  to  mental  disease.  His  professional 
Avork  became  a  burden  to  him,  and  he  lost  all  confidence  in  doing  it,  so 
that  he  had  to  give  it  up.  He  did  not  sleep  well,  became  much  depressed, 
and  was  very  miserable,  obstinate,  and  hypochondriacal.  He  had  quite 
made  up  his  mind  that  he  was  not  to  get  better,  and  would  do  nothing 
towards  his  own  cure.  He  did  not  lose  his  self-control.  He  simply 
changed  his  habits,  avoided  his  friends,  neglected  his  personal  appearance, 
was  absolutely  idle,  and  might  be  said  to  have  become  morbidly  ".selfish." 
With  all  this  there  was  apparently  no  lack  of  reasoning  power,  or  general 
intelhgence,  and  this  made  the  whole  thing  the  more  trying  to  his  friends. 
When  a  man  who  cannot  reason  acts  unreasonably  allowance  is  made  for 
him,  but  when  a  man  acts  unreasonably  who  can  reason,  the  natural 
impulse  is  to  blame  him  and  hold  him  fully  responsible.  Fortunately  he 
did  not  give  up  going  out  into  the  fresh  air,  and  this  was  his  ultimate 
salvation,  for  he  slowly  improved,  and  in  the  course  of  about  five  years 
he  got  perfectly  well,  and  resumed  his  business,  though  he  never  could  do 
as  much,  and  was  never  "  quite  the  same  man,"  but  was  about  as  happy 
as  the  average  of  his  fellow-men  in  their  post-climacteric.  No  doubt  if 
he  had  taken  to  his  bed,  or  to  staying  in  the  house,  as  so  many  such  cases 
do,  he  would  never  have  recovered.  In  his  case,  as  that  of  many  others 
I  have  met  with,  the  first  decided  symptoms  of  mental  improvement  were 
coincident  with  an  eczematous  skin  eruption.  I  have  seen  gouty, 
syphilitic,  and  all  sorts  of  skin  eruptions  come  on  in  such  cases  during 
the  disease,  usually  greatly  to  the  patient's  mental  benefit. 

The  prognosis  and  other  points  in  climacteric  insanity  are  best  brought 
out  by  a  statistical  study  of  a  number  of  cases.  In  the  nine  years 
(1874-1882)  I  have  diagnosed  as  such  two  hundred  and  twenty-eight 
cases  of  the  thirty-one  hundred  and  forty-five  that  have  been  admitted 
into  the  Royal  Edinburgh  Asylum  in  that  time.  Of  these  the  large  pro- 
portion of  one  hundred  and  ninety-six  were  women,  and  only  thirty-two 
being  men.     The  table  below  shows  their  ages. 

We  see  that  by  far  the  majority  of  the  female  cases  occurred  between 


394  CLIMACTERIC    INSANITY. 

forty  and  fifty,  and  the  majority  of  the  men  between  fifty-five  and  sixty- 
five.  As  regards  the  symptomatological  forms  assumed  by  the  cases,  only 
thirteen  of  the  men  and  fifty-six  of  the  women,  or  eighteen  per  cent,  of 
the  whole,  were  acute  in  character.  It  is  essentially,  therefore,  a 
subacute  psychosis  in  its  general  character.  Of  the  whole,  only  eighty- 
two  were  cases  of  mania,  the  remaining  one  hundred  and  forty-six  being 
melancholic.  One-half  the  patients  were  suicidal  in  intent  at  least,  but 
few  of  them  have  made  very  serious  or  desperate  attempts  to  take  away 
their  lives,  though  to  this  there  were  some  exceptions.  There  was  a  high 
proportion,  but  a  low  intensity  of  suicidal  impulse. 

Males.  Females.  Total. 


35  to  40 

17 

17 

40  "  45 

74 

74 

45  "  50 

81 

81 

ryO  "  55 

7 

19 

26 

55  «'  60 

14 

5 

19 

60  "  65 

9 

9 

65  "  70 

2 

2 

32  196  228 

The  results  of  treatment  showed  that  one  hundred  and  twelve  cases,  o;* 
fifty-three  per  cent,  of  them,  recovered,  the  women  recovering  in  the 
largest  proportion.  In  fact,  only  thirty-one  per  cent,  of  the  men  got  well, 
while  fifty-seven  per  cent,  of  the  women  did  so.  The  numbers  who  died, 
on  the  contrary,  were  greater  proportionately  in  the  men  than  the 
women,  four  of  the  former,  or  twelve  per  cent.,  and  seventeen  of  the  latter, 
or  nine  per  cent,,  having  died  up  to  this  time.  This  would  seem  to 
indicate  that  the  disease  is  rarer,  less  curable,  and  more  deadly  in  the 
male  sex  than  the  female ;  but  the  numbers  are  perhaps  too  few  on 
which  to  base  a  correct  generalization. 

The  patients  who  recovered  had  not  been  so  long  ill  as  I  had  previously 
imagined.  Taking  the  time  they  were  under  treatment  in  the  asylum 
(the  only  correct  basis  I  have  on  which  to  estimate  the  duration),  sixty- 
one  of  the  one  hundred  and  twenty-two  who  recovered,  or  fifty-five  per 
cent.,  were  discharged  within  three  months,  and  eighty,  or  sixty-five 
per  cent,  within  six  months,  and  one  hundred  and  eleven,  or  ninety-one 
per  cent.,  within  twelve  months.  There  were  a  few  patients  who 
recovered  after  two  years  of  treatment.  The  maniacal  and  the  melan- 
cholic cases  recovered  in  about  equal  proportion,  but  the  maniacal  in 
shorter  time.  The  recoveries  were  much  fewer  in  the  women  over  fifty, 
only  twenty-nine  per  cent,  of  these  getting  better.  Up  to  fifty  they 
recovered  equally  well.  At  the  other  ages,  from  fifty-five  to  sixty,  the 
cases  were  the  most  curable  in  the  men.  Only  three  of  the  eleven  over 
sixty  got  over  their  malady.' 

^  These  statistics  may  be  profitably  compared  with  those  of  Dr.  Merson's  admirable 
paper  on  this  subject,  in  the  We^t  Riding  Lunatic  Asvlum  Medical  Eeports,  vol.  vi. 
p.  85. 


SENILE    INSANITY.  395 


SENILE   INSANITY. 


The  psychology  of  nonnal  old  age  has  yet  to  be  written  from  the 
purely  physiological  and  brain  point  of  view.  Poets,  dramatists,  and 
novelists  have  had  much  to  say  of  it  from  their  standpoint.  King  Lear 
is  beyond  a  doubt  a  truthful  delineation  of  senility,  partly  normal  and 
partly  abnormal.  By  normal  senility  I  mean  the  purely  physiological 
abatement  and  decay  in  the  mental  function  running  pari  passu  with  the 
lessening  of  energy  in  all  the  other  functions  of  the  organism  at  the  latter 
end  of  life.  No  doubt,  in  an  organism  with  no  special  hereditary  weak- 
nesses and  that  had  been  subjected  to  no  special  strains,  all  the  functions 
except  the  reproductive  should  decline  gradually  and  all  together,  and 
death  would  take  place,  not  by  disease  in  any  proper  sense,  but  through 
general  physiological  extinction.  The  great  function  of  reproduction 
stands  in  a  different  position  from  all  the  other  functions  of  the  organism. 
It  arises  differently,  it  ceases  differently,  and  it  is  more  affected  by  the  sex 
of  the  individual  than  any  other  function.  It  is,  as  a  matter  of  fact,  not 
entirely  dependent  on  individual  organs.  It  may  exist  as  a  desire  and  an 
instinct  without  testes,  or  ovaries,  or  sexual  organs.  It  is  really  an  essential, 
all-pervading  quality  of  the  whole  organism,  and  to  some  extent  of  every 
individual  organ,  not  one  of  which  has  entirely  lost  the  primordial  fissi- 
parous  tendency  to  multiply.  But  the  physiological  period  of  the 
climacteric  has  determined  and  ended  it  in  its  intensity  and  greatest  power, 
though  many  of  its  adjuncts  remain ;  and  in  the  male  sex  we  have  to 
reckon  with  it  and  its  abnormal  transformations  to  some  extent  even  in 
the  senile  period  of  life. 

Physiological  senility  typically  means  no  reproductive  power,  greatly 
lessened  affective  faculty,  diminished  power  of  attention  and  memory, 
diminished  desire  and  power  to  energize  mentally  and  bodily,  lowered 
imagination  and  enthusiasm,  lessened  adaptability  to  change,  greater 
slowness  of  mental  action,  slower  and  less  vigorous  speech  as  well  as 
ideation,  fewer  blood- corpuscles  red  and  white,  lessened  power  of  nutrition 
in  all  the  tissues,  a  tendency  to  disease  of  the  arteries,  a  lessening  in  bulk 
of  the  whole  body,  but  notably  of  the  brain,  which  alters  structurally  and 
chemically  in  its  most  essential  elements,  the  cellular  action  and  the  nerve 
currents  being  slower,  and  there  being  more  resistance  along  tRe  con- 
ducting fibres. 

In  the  young  man  there  is  an  organic  craving  for  action,  which,  not 
being  gratified,  there  results  organic  discomfort ;  in  the  old  man  there  is 
an  organic  craving  for  rest,  and  not  to  gratify  that  causes  organic  uneasi- 
ness. 

The  three  great  dangers  to  nonnal  mental  senility  are  hereditary  brain 
weakness,  a  diseased  vascular  system,  and  the  after-effects  of  over- 
exertion or  abnormal  disturbance  of  brain  function  at  former  periods  of 
life  which  have  left  the  convolutions  weakened.  The  hereditary  predis- 
position to  mental  disease  that  has  not  shown  itself  till  after  sixty  must, 
no  doubt,  have  been' slight  or  well  counteracted  in  the  conditions  of  life, 
yet  in  many  brains  it  never  shows  itself  till  then.  Until  the  organ  had 
begun  physiologically  to  lose  its  structural  perfection  and  its  dynamical 


396  SENILE    INSANITY. 

force,  the  pathological  phenomenon  that  we  call  mental  disease  was  not 
developed.  As  we  shall  see  from  a  statistical  study  of  clinical  cases, 
heredity  to  insanity  was  less  common  in  the  cases  of  senile  insanity  than 
in  any  other  form  of  mental  disease  except  general  paralysis  ;  but  there 
is  this  fallacy,  that  the  facts  about  heredity  were  further  back  and  more 
forgotten  in  this  than  in  any  other  form.  An  old  man's  living  relatives 
are  few,  and  his  ancestors'  history  far  off.  We  may  put  it  down  as 
a  certain  law  of  nervous  heredity,  that  the  stronger  the  predisposition  the 
sooner  it  manifests  itself  in  life,  and  the  weaker  it  is  the  later  in  life  it 
shows  itself.  To  have  survived,  therefore,  the  changes  and  chances,  the 
crises  and  perils  of  life  with  intact  mental  function  till  after  sixty,  means 
slight  neurotic  heredity  or  great  absence  of  exciting  causes  of  disease. 

It  is  impossible  to  fix  an  age  at  which  physiological  senility  begins,  and 
therefore  we  cannot  fix  an  age  for  senile  insanity.  Some  men  are  older 
at  fifty  than  others  are  at  seventy.  I  believe  that  in  some  cases  neurotic 
heredity  assumes  the  special  outcome  of  early  senility — that  is,  of  early 
wear-out  or  poor  organic  staying  power.  Most  congenital  imbeciles  and 
idiots  grow  old  soon.  Very  many  races  of  men  grow  old  early,  like  the 
Kalmucs  and  Hottentots ;  but,  roughly  speaking,  in  our  race  one  cannot 
call  a  man  old  till  he  is  sixty,  though  I  have  often  met  with  senile  mental 
symptoms  between  fifty  and  sixty,  and,  as  we  know,  atheromatous 
arteries  and  consequent  tissue  degenerations  are  common  enough  before 
then.  But  in  speaking  of  senile  insanity,  I  shall  include  no  one  under 
sixty  years  of  age. 

It  is,  of  course,  a  well-known  fact  that  mental  disease,  speaking  gen- 
erally, is  a  disease  of  middle  and  advanced  life  rather  than  of  youth.  Of 
the  general  population  under  20  a  very  small  percentage  become  insane. 
Only  0.9  per  10,000  of  the  general  population  under  that  age  are  sent 
to  asylums  in  a  year  in  England  and  Wales,  while  11.4  per  10,000  over 
60  are  so  sent,  or  about  twelve  times  the  proportion. 

The  best  foundation  for  what  I  have  to  say  of  senile  insanity  will  be 
the  chief  statistical  and  clinical  facts  recorded  about  203  cases  (71  males 
and  132  females)  that  have  been  classified  under  that  heading  in  the  nine 
years'  admissions  to  the  Royal  Edinburgh  Asylum,  1874—82.  The  total 
number  of  patients  admitted  in  that  time  was  3145,  and  they  were  of  all 
classes,  from  the  sons  of  peers  of  the  realm  down  to  the  lowest  beggar. 
Of  these,  304,  or  9.6  per  cent.,  were  over  60  years  of  age.  One  remem- 
bers this  better  by  thinking  that  one-tenth  of  them  were  over  60.  But 
of  these  304  cases  only  203  were  called  by  me  senile  insanity.  The  other 
101  were  mostly  epileptics,  old  cases  of  long-existing  mania  or  dementia, 
or  cases  of  climacteric  insanity — that  is,  old  age  had  acted  as  a  predis- 
posing or  exciting  cause  of  the  mental  disease,  and  the  symptoms  were 
more  or  less  characteristic  of  senility  in  those  203  cases  only.  Six  and 
a  third  per  cent,  of  the  whole  admissions,  or  one-sixteenth  of  them,  were 
thus  cases  of  senile  insanity.  It  is,  therefore,  a  common,  but  not  the 
most  common,  form  of  insanity,  as  compared  with  the  other  clinical 
varieties  of  mental  disease. 

The  great  predisposing  cause  of  insanity,  heredity,  appeared  to  be, 
as  I  have  said,  very  uncommon.  Only  26  of  the  cases,  or  13  per  cent., 
were  so  affected.     In  estimating  the  frequency  of  heredity  in  mental  dis- 


SENILE    INSANITY.  397 

ease,  one  has  to  add  an  enormous  margin  for  ignorance  and  conscious  or 
unconscious  concealment  of  facts.  In  the  nine  years  under  review,  723 
of  the  whole  3145  cases,  or  23  per  cent.,  were  ascertained  to  be  heredi- 
tary. The  senile  heredity,  therefore,  was  little  more  than  half  the  ordi- 
nary average  heredity. 

The  form  assumed  by  the  different  cases  is  a  question  of  great  interest. 
I  confess  I  was  myself  astonished  at  the  immense  variety  of  mental 
symptoms  present.  Till  I  had  these  203  cases  analyzed,  I  had  not  fully 
realized  either  the  character  or  the  results  of  treatment  of  the  disease. 
Looking  first  at  the  presence  or  absence  of  mental  depression  or  mental 
pain,  I  find  that  69  of  these  cases,  or  about  a  third,  were  depressed,  and 
classified  by  me  as  laboring  under  melancholia.  To  feel  pain,  mental  or 
bodily,  the  brain  needs  to  be  to  a  certain  extent  sensitive  and  active 
functionally.  But  the  peculiarity  of  many  of  the  cases  of  senile  insanity 
was,  that  the  mental  depression  was  merely  outward  in  muscular  expres- 
sion, not  heing  felt  in  any  proper  subjective  sense,  and  it  was  certainly 
not  remembered.  It  was,  in  fact,  automatic  motor  misery,  and  not  con- 
scious, sensitive,  mental  pain.  One  of  the  cases  lately  under  my  care 
illustrates  this  very  well :  L.  A.,  set.  83  at  death.  His  mental  power 
had  been  failing  for  three  or  four  years.  At  first  there  were  failure  of 
memory,  irritability,  exaggerated  opinions  of  himself,  morbid  suspicions, 
sleeplessness,  restlessness,  and  lack  of  self-control.  These  symptoms 
gradually  got  worse,  until  his  memory  was  quite  gone,  and  he  did  not 
know  his  age,  or  his  wife,  or  his  home.  Yet  his  appetite  was  good,  his 
health  in  some  respects  better  than  it  had  been  before,  for  a  gouty  ten- 
dency had  disappeared.  He  looked  fresh  and  well,  and  his  muscular 
strength  in  spurts  was  very  great  indeed.  He  had,  a  year  or  so  after  the 
beginning  of  the  attack,  a  sort  of  hemiplegic  attack,  transient  and  slight ; 
and  ever  since  it  began,  and  going  along  with  it  as  one  of  the  symptoms 
of  the  disease,  there  was  a  slight  indistinctness  of  speech,  a  want  of  motor 
activity  and  perfect  coordination  in  the  articulatory  muscles,  a  change  in 
the  tone  of  the  voice  in  the  direction  of  feebleness,  a  difiiculty  in  finding 
words,  a  tendency  to  stop  in  the  middle  of  sentences,  an  omission  of 
words,  especially  nouns — in  fact,  the  typical  senile  speech,  with  its  mix- 
ture of  aphasic,  amnesic,  and  paretic  symptoms.  The  senile  speech  I 
look  on  as  just  as  characteristic  as  the  aphasic,  the  general  paralytic,  or 
the  hemiplegic  speech,  and  just  as  illustrative  of  brain  function.  He 
had  all  the  signs  of  advanced  atheroma  of  his  vessels. 

About  the  middle  period  of  his  disease,  his  memory  was  quite  gone  for 
recent  things,  and  you  could  scarcely  engage  his  attention  for  more  than 
a  few  seconds  on  any  one  subject.  At  times,  in  fact,  mostly,  he  showed 
a  kind  of  happy  negative  contentment.  If  you  could  get  the  thread  of 
his  old  life,  he  Avould  tell  old  stories,  make  speeches,  and  look  as  wise  as 
possible ;  but  all  this  time  he  did  not  know  who  you  were,  or  where  he 
was,  or  the  day  of  the  week,  or  the  month,  or  the  year,  or  what  he  had 
for  dinner.  Then  suddenly,  without  any  outward  cause,  a  change  would 
come  over  him.  He  would  look  most  miserable,  would  moan,  and  groan, 
and  weep  (tearlessly),  Avring  his  hands,  uttering  disjointed  exclamations 
of  sorrow ;  but  he  could  not  tell  you  what  grieved  him,  and  in  a  minute 
or  two  he  might  be  quite  cheerful,  and  he  remembered  nothing  about  it, 


398  SENILE    INSANITY. 

denying  that  he  was  at  all  dull  or  ever  had  been  so.  Or  he  would  at 
times  suddenly,  causelessly,  become  intensely  suicidal,  trying  to  strangle 
himself,  running  his  head  against  the  wall,  or  clutching  his  throat  with 
his  hands.  In  that  condition  you  could  not  rouse  his  attention.  He  was, 
in  fact,  practically  unconscious,  and  when  controlled  or  prevented  carry- 
ing out  his  suicidal  attempts,  he  would  struggle  and  resist  desperately 
and  unreasoningly.  At  other  times  he  would  have  sudden  homicidal 
attacks.  But  in  half  an  hour  after  all  this  he  would  be  calm,  chatty, 
and  utterly  oblivious  of  everything  that  had  occurred.  The  whole  thing, 
in  fact,  the  pain,  the  suicidal  and  the  homicidal  impulses,  were  so  many 
automatic  acts  unaccompanied  by  motive,  reason,  or  remembrance,  and 
were  the  mere  motor  signs  of  some  organic  discomfort.  All  his  worst 
symptoms  used  to  come  on  at  night,  when  he  would  become  noisy,  rest- 
less, shouting,  resisting,  and  quite  unmanageable,  alarming  the  household 
and  neighborhood.  The  continuance  of  those  symptoms  wore  out  every- 
one connected  with  him.  Of  all  forms  of  insanity,  the  senile  is  apt  to 
become  most  aggravated  at  night.  It  might  be  supposed  that  there  could 
scarcely  be  any  conceivable  circumstances  under  which  a  man  of  that  age, 
with  means  enough  to  procure  proper  attendance,  would  have  to  be  sent 
from  his  own  home.  Yet  those  circumstances  occurred.  Home  treat- 
ment was  a  failure,  and  could  not  be  any  longer  persisted  in.  Certainly 
he  did  better  in  a  villa  of  the  asylum,  with  plenty  of  fresh  air  and  regu- 
lated exercise  "little  and  often,"  regularity  of  life,  lots  of  milk  and  eggs, 
and  digestible,  plain  food,  and  good  skilled  attendance ;  getting  fat  and 
sleeping  far  better.  But,  of  course,  he  slowly  got  more  enfeebled  in 
mind ;  his  suicidal  impulses  became  less  intense,  his  noise  at  night  less, 
and  his  resistiveness .  more  controllable,  but  his  motor  restlessness  re- 
mained. All  his  symptoms  were  irregularly  periodic  and  remissional. 
For  months  he  would  be  quiet,  and  then  would  have  a  few  weeks  of 
motor  excitement,  and  night  noise,  and  impulsiveness.  What  is  the 
cause  of  these  aggravations  in  senile  cases — and  they  are  very  common, 
almost  universal  ?  I  really  do  not  know.  I  presume  one  must  look  on 
them  as  being  partly  mere  action  and  reaction,  activity  and  exhaustion 
simply.  In  such  a  case  we  can  have  no  reproductive  periodicity  to  deal 
with.  He  died  of  simple  senile  exhaustion,  but  with  resistance  to  feed- 
ing, restlessness,  and  noise  to  some  extent,  up  till  three  days  of  his  death. 
It  is  very  difficult  to  know  how  to  classify  such  a  case  symptomatologi- 
cally.  There  was  undoubted  dementia,  and  there  was  maniacal  excite- 
ment. There  were  all  the  outward  signs  of  suicidal  melancholia,  and  the 
symptoms  of  true  impulsive  insanity.  I  adopt  the  rule,  that  wherever 
there  is  marked  mental  pain,  or  the  outward  signs  of  it,  the  case  is  put 
down  as  melancholia  in  our  books.  L.  A.'s  case  is  a  typical  example  of 
pure  senile  insanity  of  the  melancholic  type.  But  many  of  the  cases  of 
senile  insanity  classified  symptomatologically  as  melancholia  were  entirely 
different  from  this  case.  Several  of  them  were  cases  of  simple  melan- 
cholia that  proved  to  be  transient,  its  only  special  senile  character  being 
that  it  occurred  in  old  people,  was  accompanied  by  more  loss  of  memory 
than  usual,  and  the  recovery  it  ended  in  had  somewhat  of  normal  senility 
in  it.  Several  of  the  cases  were  caused  proximately  by  bodily  diseases 
that  exhausted  the  strength  or  lessened  the  blood-corpuscles,  or  by  moral 


SENILE    INSANITY.  399 

causes.  It  is  quite  common  in  my  experience,  and,  I  believe,  in  that  of 
all  medical  practitioners,  to  find  certain  old  persons  much  depressed  in 
mind  by  any  bodily  disease.  Notably  I  have  seen  this  happen  in  the 
course  of  bronchitic  or  heart  troubles,  where  the  blood  was  not  aerated. 
In  fact,  given  a  senile  brain,  atheromatous  arteries,  and  non-aerated 
blood,  and  we  are  pretty  certain  to  have  the  mental  functions  of  the  brain 
affected.  I  am  in  the  habit  of  speaking  loosely  of  "cyanotic  delirium  " 
and  "  cyanotic  insanity"  from  the  non-oxygenation  of  the  blood  in  bron- 
chitic and  cardiac  disease.  Others  of  my  cases  of  senile  melancholia  had 
fixed  melancholic  delusions.  Intense  suicidal  feelings  were  rare,  and 
very  determined  attempts  still  more  rare,  but  we  cannot  depend  on  this 
rule  in  all  cases.  Of  the  sixty-seven  melancholic  cases,  seventeen  were 
acute  in  symptoms,  and  fifty  were  mild. 

Of  the  melancholic  patients,  thirty  per  cent,  were  discharged  as  tech- 
nically "  recovered  " — that  is,  in  all  of  them  their  worst  mental  symp- 
toms disappeared,  they  passing  into  normal  senility.  In  many  cases  they 
became  quite  well  in  an  absolute  sense.  In  the  melancholic  patients, 
speaking  generally,  the  recoveries  were  apt  to  be  better  than  in  any  other 
class  of  senile  cases,  as  in  the  following  example : 

L.  B.,  set.  77,  a  man  of  reserved  disposition,  steady  and  temperate 
habits.  There  was  no  known  heredity  to  insanity.  He  had  never  shown 
any  disposition  to  depression  of  mind  before.  He  had  done  his  modest 
work  in  life  well ;  had  brought  up  a  healthy  and  well-doing  family,  and 
was  an  intelligent  and  religious  man.  His  business  was  not  prospering, 
and  he  became  depressed  and  restless.  He  imagined  he  was  eternally 
lost,  that  the  diminution  of  his  business  was  a  direct  judgment  of  God 
for  his  sins.  This  in  religious  people,  and  in  irreligious  ones,  too,  is  a 
very  common  melancholic  delusion,  and  the  public  will  always  have  it 
that  any  kind  of  religious  delusion  or  "religious  insanity  "  is  a  very  bad 
symptom  in  every  case,  and  necessarily  incurable.  Now  there  is  only  a 
little  truth  in  this.  The  idea  has  arisen,  no  doubt,  from  the  fact  that  the 
cases  with  fixed  delusions  of  a  religious  kind — the  prophets  of  the  Lord, 
the  sons  of  God,  the  possessed  with  a  devil — are  usually  incurable,  and 
such  cases  make  a  very  strong  impression  on  the  public  mind.  L.  B. 
gradually  got  worse,  and  talked  of  committing  suicide  by  throwing  him- 
self over  the  North  Bridge — a  fearfully  suggestive  and  then  low-parapeted 
place.  After  eighteen  months  of  treatment  at  home,  he  got  so  ill  that  he 
was  sent  to  the  asylum.  On  admission  he  was  depressed,  restless,  un- 
settled, and  talkative,  Avith  religious  delusions.  He  looked  an  old  man, 
with  atheromatous  arteries,  and  there  were  senile  cataract  and  marked 
heart  disease ;  but  his  appetite  was  good,  and  his  general  nutrition  and 
strength  very  fair  for  his  age.  He  did  not  sleep  well  at  first.  He  was 
ordered  Parrish's  syrup  of  the  phosphates,  cod-liver  oil,  with  milk  diet, 
and  fresh  air  when  the  weather  was  suitable.  There  was  a  hypochon- 
driacal character  about  his  mental  depression  all  the  time.  In  about  two 
months  he  had  strengthened  and  improved.  He  became  more  obviously 
concerned  about  the  state  of  his  bowels  than  that  of  his  soul.  He  was 
one  of  the  melancholies  —  a  numerous  array — who  heard  "the  clock 
strike  every  hour  of  the  night."  In  about  nine  months  he  was  almost 
free  from  the  mental  depression,  and  his  memory  had  got  better,  while 


400  SENILE    INSANITY. 

he  looked  quite  ruddy  and  hale.  In  a  year  he  was  really  quite  well,  and 
was  sent  to  his  home  just  as  cheerful  and  more  active  than  the  average 
man  of  seventy-eight.  He  came  out  to  see  us  for  three  years  after,  in  no 
respect  the  worse,  mentally  or  physically,  for  his  interlude  of  two  and  a 
half  years  of  senile  depression  and  insanity,  and  he  died  peacefully  at 
home  in  his  eighty-fourth  year. 

Turning  now  to  the  cases  that  showed  no  melancholic  symptoms,  or, 
at  all  events,  where  such  symptoms  were  not  long  continued  or  prevailing. 
There  were  134  of  these,  all  of  whom  having  some  sort  of  motor  excite- 
ment, they  were  put  down  at  first  as  cases  of  "mania."  As  I  do  not 
recognize  "dementia"  to  be  curable  when  used  in  a  correct  sense,  I 
scarcely  ever  at  first  diagnose  any  recent  case  as  such,  no  matter  what 
the  symptoms  are  at  the  time.  To  my  mind,  a  patient  is  only  proved  to 
labor  under  dementia  when  he  is  proved  by  lapse  of  time  to  be  incurable, 
and  has  the  symptoms  of  mental  enfeeblement  as  well.  Many  of  these 
134  senile  cases  were  really  cases  of  dementia,  but  I  put  them  down  as 
mania  at  first,  because  their  enfeeblement  of  mind  had  not  been  proved 
to  be  incurable,  and  because  they  had  more  or  less  motor  excitement.  In 
only  19  of  these  was  the  excitement  so  intense  as  to  be  classified  as  acute 
mania.  The  mental  symptoms  in  these  134  cases,  like  those  of  the 
melancholy  cases,  were  very  different  in  kind  and  degree,  duration  and 
result.  Some  were  short  sharp  brain-storms  preceding  death,  outbursts 
of  delirious  excitement  accompanying  the  break-up  of  the  organism. 
Instead  of  a  long  and  gradually  progressive  failure  of  convolutional  func- 
tion, in  such  cases  it  ended  in  a  quick  and  tumultuous  fashion.  Instead 
of  mere  loss  of  power  from  innate  trophic  failure  and  want  of  blood,  in 
such  cases  there  is  a  vaso-motor  paralysis  and  a  development  of  irregular 
cellular  energy,  expressed  outwardly  by  constant  talking,  shouting,  inco- 
herence, loss  of  memory,  loss  of  attention,  sleeplessness,  and,  above  all, 
by  a  constant  motor  restlessness  by  night  and  day,  but  especially  by 
night.  This  was  such  a  case:  L.  C,  set.  78.  He  had  been  pretty  well 
up  to  three  months  ago,  and  at  that  time  the  excitement  and  exertion  of 
moving  from  one  house  into  another  seemed  to  exhaust  him.  He  first 
became  stupid  and  peculiar,  and  this  come  on  suddenly,  being  noticed 
particularly  .one  morning.  He  gradually  became  excited,  incoherent, 
threatening,  unmanageable,  and  his  memory  was  lost,  but  for  ten  days 
only,  before  being  sent  to  the  asylum,  had  he  been  very  excited.  The 
whole  household  and  neighbors  were  disturbed  by  his  noise,  and  his 
friends  and  doctor  decided  that  he  must  be  sent  to  an  asylum.  On  ad- 
mission, he  was  weak  muscularly,  spoke  with  the  voice  and  articulation 
of  a  very  old  man ;  he  was  confused,  and  his  memory  was  gone.  He 
said  he  was  forty,  and  could  not  answer  almost  any  question  correctly. 
His  heart's  action  was  weak,  and  there  were  moist  rales  heard  all  over 
his  chest,  but  there  was  no  acute  disease,  his  temperature  being  98.4°, 
and  his  pulse  80.  The  left  side  of  his  face  was  slightly  paralyzed,  and 
his  pupils  unequal.  There  was  no  paralysis  of  arm  or  legs.  He  did 
not  sleep,  and  was  noisy  and  excited  all  night.  There  was  much  diffi- 
culty in  making  him  take  his  food,  too.  His  bronchitis  was  bad,  and  his 
cough  very  troublesome.  Within  forty-eight  hours  after  admission,  he 
got  pale  and  weak,  his  breathing  became  labored,  and  he  died  suddenly 


SENILE    INSANITY.  401 

that  day.  There  was  no  post-mortem  examination.  His  relatives  natu- 
rally were  very  sorry  they  sent  him  to  the  asylum,  and  were  inclined  to 
blame  the  doctor  who  recommended  it.  No  doubt,  if  the  result  could 
have  been  foreseen,  no  one  would  have  recommended  his  leaving  home, 
but  I  do  not  think  there  were  any  definite  symptoms  present  pointing  to 
the  result.  When  consulted  about  cases  of  senile  insanity,  I  always  have 
before  my  mind  the  question,  "Are  those  mental  symptoms  not  the  mere 
forerunner  and  accompaniment  of  a  general  break-up  ?"  And  to  answer 
that  question  it  is  desirable  to  go  into  the  condition  of  the  brain,  the 
heart,  the  lungs,  the  kidneys,  and  the  general  strength  very  carefully.  I 
am  always  suspicious  of  sudden  oncomings  of  mania  in  old  people  being 
of  this  character. 

The  following  case  was  typical  in  its  inception,  symptoms,  incidents, 
duration,  and  pathology :  L.  D.,  ^t.  78.  Had  been  hard-working,  and 
as  drunken  as  his  limited  means  would  allow.  Senile  insanity  is  often 
the  penalty  for  an  excessive  use  of  alcohol  in  earlier  life.  About  nine 
months  ago  he  got  a  fall  down  stairs,  and  has  not  been  so  strong  or  well 
since.  About  six  months  ago,  his  memory  began  to  fail,  then  he  became 
stupid  and  confused,  then  suspicious,  then  restless,  then  unmanageable, 
then  violent  to  his  wife,  and  was  then  sent  to  the  asylum  as  a  pauper 
patient.  On  admission,  he  was  confused,  slightly  excited,  very  restless, 
his  memory  gone,  his  general  condition  Aveak,  his  senses  blunted,  his 
speech  senile,  his  pupils  irregular  in  outline,  his  tongue  tremulous,  his 
pulse  90,  weak  and  intermittent,  his  temperature  98.2°,  his  lungs  and 
other  organs  healthy,  and  his  appetite  good.  He  was  well  fed  and  nursed 
in  our  hosj^ital  ward,  but,  though  he  gained  in  flesh,  he  did  not  improve. 
He  was  restless,  especially  at  night,  became  gradually  dirty  in  his  habits, 
moved  about  in  a  purposeless  way  all  the  time.  The  motor  restlessness 
of  a  senile  case  is  an  extraordinary  vital  phenomenon.  He  never  sits 
down,  seldom  sleeps,  he  shouts,  and  walks  about  his  room  all  night,  and 
yet  never  tires.  I  found  that  this  symptom  existed  in  sixty  per  cent,  of 
all  the  cases.  Whence  the  source  of  all  this  most  unnatural  muscular 
energy  ?  It  exhausts  his  small  stock  of  real  strength,  though  he  does 
not  feel  it.  It  is  the  antipodes  of  the  quietude  and  disinclination  for 
exertion  of  the  normal  old  man. 

About  three  months  after  admission,  as  he  was  aimlessly  carrying  a 
chair  in  the  day-room,  he  slipped,  falling  down,  and  breaking  his  right 
femur  at  the  neck  inside  the  capsule,  an  accident  always  liable  to  happen 
to  a  senile  patient.  He  got  on  pretty  well,  being  left  in  bed  and  nursed 
and  cared  for  as  well  as  was  possible.  In  about  two  months  the  restless- 
ness came  on  again,  and  in  trying  to  rise  he  hurt  his  leg  again.  In  about 
a  month  he  died  of  exhaustion,  having  been  ill  for  ten  months,  there 
being  much  diflBculty  in  preventing  the  formation  of  bed-sores  before 
death.  The  difiiculty  of  managing  such  cases  satisfactorily  in  an  asylum 
or  out  of  it  is  extreme.  They  are  very  restless,  always  meddling  with 
something  or  somebody,  very  obstinate,  entirely  forgetful  and  purposeless. 
They  are  constantly  making  their  water  on  the  floor,  in  a  corner  of  the 
room,  or  in  another  patient's  hat.  They  need  bathing  often.  Their 
boAvels  are  either  too  costive  or  too  loose.  They  are  liable  to  retention  of 
urine  from  enlarged  prostates  and  bladder  paralysis.     They  either  eat  too 

26 


402  SENILE    INSANITY. 

much  or  will  not  eat  at  all.  A  slight  fall  breaks  their  bones.  To  lie 
near  other  maniacal  or  irritable  patients  is  out  of  the  question,  for  they  are 
sure  to  get  hurt.  For  them  one  requires  to  use  the  best  attendants,  the 
best  single  rooms  at  night,  and  the  best  parts  of  a  fully-equipped  hospital 
ward ;  and  all  this  needs  to  be  done  by  nurse  and  doctor  under  the 
depressing  feeling  that  it  is  of  no  use  in  the  long  run  towards  the  cure  of 
the  patient. 

On  a  post-mortem  examination  of  L.  D's.  case  the  pia  mater  and 
arachnoid  were  found  thick  and  opaque,  but  stripping  freely  off  the  con- 
volutions, which  were  over  the  vertex  of  the  brain  atrophied  and  covered 
with  an  opaque  compensatory  fluid.  On  section  the  gray  substance 
of  the  convolutions  Avas  irregularly  thinned  and  soft  in  texture,  the  peri- 
vascular canals  being  enormously  enlarged.  In  the  extra-ventricular 
nucleus  of  the  left  corpus  striatum  there  was  a  recent  hemorrhage  the  size 
of  a  pea,  and  in  the  right  optic  thalamus  one  of  the  same  size  of  older 
date.  There  was  a  small  softening  from  embolism  or  thrombosis  in 
another  part  of  the  thalamus.  The  lining  membranes  of  all  the  ventri- 
cles were  granular,  and  the  lateral  ventricles  were  enlarged  from  intersti- 
tial brain  atrophy.  All  the  brain  arteries  were  atheromatous  in  patches, 
causing  diminution  of  their  lumen  at  these  points.  There  was  dilatation 
of  both  ventricles ;  aorta  was  very  atheromatous,  lungs  were  oedematous, 
liver  slightly  nutmeggy,  right  kidney  disorganized  and  the  seat  of  an 
extravasation  of  blood.  On  microscopic  examination  the  large  cells  in 
the  inner  layers  of  the  convolutions  were  found  in  the  degenerated 
atrophied  state,  with  their  processes  gone,  as  represented  in  Dr.  Major's 
plate  (Plate  VIII.  Fig.  4).^  There  was  much  debris  round  the  vessels  in 
the  perivascular  canals.  In  some  few  of  the  cases  the  pathological 
appearances  are  indicative  of  a  much  more  intensely  disturbed  state  of  the 
convolutions  during  life.  For  instance,  in  a  case  I  examined,  L.  E., 
set.  76,  who  had  been  ill  for  fifteen  months,  the  last  three  of  which  were 
spent  in  the  asylum,  and  who  had,  in  addition  to  the  symptoms  of  the  last 
case,  great  violence  at  times,  wanting  to  get  out  of  his  house,  which  he 
maintained  was  not  his  own,  an  epileptiform  attack,  a  very  indistinct, 
thick,  scarcely  intelligible  articulation,  all  his  symptoms  remissional,  more 
emotionalism,  and  a  temperature  of  from  99°  to  100°,  we  found  after  death 
great  adherence  of  the  dura  mater  to  the  skull-cap,  and  a  very  dark- 
colored  false  membrane,  varying  from  a  quarter  of  an  inch  in  thickness, 
covering  the  whole  of  the  vertex,  and  descending  down  and  covering  the 
base  in  a  thin  layer.  In  this  membrane  there  were  several  pure  blood- 
coagula  from  the  size  of  a  pea  up  to  that  of  a  small  walnut.  The  pia 
mater  was  not  adherent  (though  in  two  or  three  senile  cases  I  have  found 
it  to  be  so),  the  ventricles  were  granulated,  and  there  was  much  general 
atrophy.  There  was  hypertrophy  of  the  muscular  substance  of  the  heart 
and  aortic  incompetence. 

The  following  is  a  case  of  transient  senile  mania  ending  in  recovery : 
L.  F.,  set.  63,  a  man  of  a  cheerful  disposition  and  somewhat  intemperate 
habits.  By  the  way,  liquor  undoubtedly  affects  an  old  man  far  more  than 
a  young  one  in  the  direction  of  producing  insanity  as  well  as  less  marked 

*  West  Riding  Medical  Reports,  vol.  v.  p.  161. 


SENILE    INSANITY.  403 

neuroses.  It  tends  more  towards  tissue  degeneration  at  advanced  ages, 
and  the  nerve  tissue  suffers  most  in  neurotic  subjects.  There  Avas  some 
insanity  in  the  family,  but  he  came  of  an  otherwise  sound,  long-lived  stock. 
Three  months  ago  he  had  an  old  ulcerated  leg  healed  up.  Had  a  perineal 
abscess  a  fortnight  ago,  which  was  opened,  and  since  then  has  been 
affected  in  mind.  The  attack  is  recent,  and  came  on  suddenly.  He 
began  to  take  fancies  that  he  was  rich,  got  excited,  and  had  a  great  crav- 
ing for  drink,  which  he  indulged,  and  got  much  worse  after  it.  On 
admission  he  Avas  greatly  exalted,  saying  he  was  possessed  of  all  knowledge, 
power,  and  wealth.  He  was  excited,  shouting  and  crying,  said  he  was 
the  "Messiah  God,"  that  he  had  millions  of  money.  He  did  not  sleep, 
and  his  appetite  was  poor.  He  was  dirty  in  his  habits,  and  constantly 
restless.  He  was  fed  well,  and  got  tonics,  chieliy  iron  and  quinine. 
AV'ithin  a  month  was  quiet  and  almost  rational  and  free  from  delusions. 
In  about  three  weeks  more  he  began  to  suffer  from  headaches,  and  soon 
became  melancholic  and  morbidly  anxious  about  his  health.  After  having 
begun  to  sleep  well,  he  again  lost  the  power  of  sleeping  in  this  melan- 
cholic stage.  In  about  another  month  he  gradually  got  out  of  the 
depression,  and  passed  into  a  quietly  contented,  rational  sane  senility. 
He  went  home,  and  ended  his  days  in  peace  after  some  years.  He 
entered  on  the  attack  a  middle-aged-looking  man ;  he  came  out  of  it 
visibly  an  old  man  in  body  and  mind,  but  in  no  respect  a  dotard  or  unfit 
to  manage  his  affairs  in  a  quiet  way.  This  was  a  case  of  senility  ushered 
in  by  a  brain-storm.  Mentally  he  at  first  resembled  a  typical  general 
paralytic. 

Looking  at  senile  insanity  broadly,  there  is  no  doubt  that  its  pure  type 
is  to  be  found  in  the  restless,  sleepless  dotard,  without  memory,  without 
true  affectiveness  (at  the  beginning  of  the  disease  there  are  often  affective 
hypersesthesia  and  uncontrollable  emotionalism),  without  crisp,  articulate 
speech- — second  childhood  in  an  unmanageable  form,  in  fact.  That  is  the 
true  senile  dementia,  out  of  which  there  can  be  no  issue  but  death.  Of 
this  class  of  case  there  were  in  a  typical  form  sixty-two  cases  of  the  two 
hundred  and  three,  or  thirty  per  cent.  That  statistical  result  was  a 
surprise  to  me.  I  had  expected  more  of  that  type.  Some  of  the  others 
seemed  to  be  of  that  character  at  one  period  of  the  attack,  but  they  came 
back  to  something  like  normal  mild  senility.  As  might  have  been 
expected  on  physiological  grounds,  the  typical  cases  of  senile  dementia 
Avere  found  in  greatest  numbers  at  the  more  advanced  ages,  but  from 
sixty  up  to  seventy-five  there  was  no  regular  increase  in  their  number. 
Under  seventy-five  there  were  only  eighteen  per  cent,  of  typical  dotards ; 
over  seventy-five  there  were  over  fifty  per  cent. 

Some  of  the  cases  were  quite  strong  in  body,  and,  beyond  some  arterial 
degeneration,  showed  no  signs  of  bodily  disease,  and  their  mental  condi- 
tion was  a  cheerful  forgetful  enfeeblement.  I  have  one  such  man  of 
seventy,  as  good  a  garden  worker  as  we  have,  who  sleeps  well  and  eats 
well,  but  cannot  tell  you  the  day  of  the  week,  calls  me  an  old  friend,  and 
has  no  idea  where  he  is.  Another  marked  type  is  that  of  pure  senile 
elevation,  with  delusions  of  great  possessions  and  power,  as  in  L.  F's.  case. 
Such  delusions,  existing  along  with  mild  maniacal  exaltation  and  the 
senile  articulation,  are  very  like  cases  of  general  paralysis.     They  are 


404  SENILE    INSANITY. 

constantly  diagnosed  as  such,  in  my  experience.  But  general  paralysis 
scarcely  ever  appears  after  sixty,  and  never  after  sixty-five.  A  close  study 
of  the  speech,  too,  Avill  usually  determine  the  difference.  There  is  not  the 
true  general  paralytic  fibrillar  trembling,  or  the  spasmodic  convulsions  of 
the  smaller  facial  and  labial  muscles.  Quite  a  number  of  cases  were 
of  that  type  in  the  early  period  of  their  disease.  One  such  case  of  sixty- 
five,  A.  H.,  had  millions  of  money  ;  the  asylum  belonged  to  him ;  he 
would  give  you  a  thousand  pounds  for  the  asking ;  he  was  happy  as  a 
king,  and  he  was  constantly  restless,  pulling  off'  his  buttons  and  taking  off 
his  clothes.  His  speech  was  thick,  hesitating,  and  wanting  in  crispness 
of  tone.  He  gradually  became  hemiplegic,  and  died  in  about  two  years, 
a  dotard.  A  large  embolic  softening  was  found  in  his  corpus  striatum,  as 
well  as  several  smaller  softenings  in  the  convolutions  of  the  motor  area 
of  the  cortex. 

Many  senile  cases  have  hallucinations  of  hearing.  I  have  now  two 
old  women  who  hold  regular  conversations  with  people  in  the  ceiling  and 
in  the  next  room.  Some  of  the  men  develop  a  morbid  eroticism  and  a 
physiological  immorality.  Many  a  marriage  I  have  known  to  be  made 
by  commencing  senile  dements.  I  had  one  patient  of  eighty,  L.  G., 
whose  conduct  towards  his  female  nurses  was  so  bad  that  few  respectable 
women  could  be  got  to  look  after  him,  and  yet  he  was  of  the  melancholic 
type,  "just  going  to  die"  every  day.  Masturbation  is  not  unknown  in 
senile  insanity.  The  hypochondriacal  mental  symptoms  that  are  certainly 
one  of  the  most  characteristic  features  of  the  cases  of  climacteric  insanity 
are  sometimes' seen  in  senile  cases.  In  most  cases  there  are  morbid  sus- 
picions at  the  beginning.  I  had  an  old  lady  patient  who  dismissed  her 
old  faithful  servant  two  or  three  times  a  week  for  stealing  her  clothes.  I 
saw  one  lately  who  believes  that  her  neighbors  come  into  her  house  and 
plot  to  rob  her  of  her  money.  The  characteristic  of  the  senile  suspicions 
is  that  they  refer  to  things  that  are  possible  to  happen,  to  stealing  of 
clothes  or  money,  to  faithlessness  on  the  part  of  near  relations,  etc.,  and 
do  not  refer  to  the  impossible  things  that  cases  of  real  monomania  of 
suspicion  believe,  to  electric  and  mesmeric  agencies,  or  to  elaborate  social 
plots.  The  senile  cases  are  constantly  changing  in  their  suspicions  and 
fancies,  too ;  one  day  it  is  one  thing,  another  day  another. 

In  a  few  of  the  cases  food  is  refused — a  very  troublesome  and  a  very 
grave  symptom.  To  feed  an  old  man  or  woman  by  the  nose-  or  stomach- 
tube  does  not  seem,  somehow,  to  be  followed  by  such  good  results  as  the 
forcible  feeding  of  younger  patients.  The  mucous  membrane  of  the  mouth 
and  fauces  is  apt  to  get  dry,  and  diarrhoea  to  set  in.  In  two  or  three 
cases  Jicematoma  auris  developed  during  the  acutely  maniacal  stage,  this 
no  doubt  indicating  marked  vascular  disease  and  trophic  disturbance. 

The  ages  of  the  cases  are  best  seen  by  a  glance  at  the  table  below. ^ 


'  Age. 

Total  Nos. 

Recovered. 

60  to  65 

62 

24 

65  "  70 

63 

21 

70  "  75 

40 

15 

75  "  80 

80 

9 

80  "  85 

3 

1 

85  "  90 

5 

2 

203  72 


SENILE    INSANITY.  405 

Taking  the  whole  number  of  cases  (203),  over  60  per  cent,  of  them  were 
between  60  and  70,  35  per  cent,  were  between  70  and  80,  and  about  4 
per  cent,  over  80.  That  is  not  far  from  the  proportion  at  those  ages  in 
the  general  population  over  60.  The  chief  diiFerence  is  that  the  propor- 
tion of  insane  persons  between  70  and  80  is  greater,  while  the  proportion 
of  the  sane  over  80  is  double  that  of  the  insane. 

One  of  the  most  interesting  and  important  of  the  results  I  obtained 
from  an  analysis  of  those  203  senile  cases  was  a  clearer  idea  than  I  had 
before  of  the  course  of  such  cases,  their  duration,  and  the  results  of  treat- 
ment. The  general  result  was  that  seventy-two  of  the  cases,  that  is,  35 
per  cent,  of  tliem,  were  discharged  from  the  asylum  recovered ;  and  sixty- 
nine  cases,  that  is,  33  per  cent.,  have  died ;  while  thirty-three  cases  were 
discharged  more  or  less  improved  or  not  at  all  improved,  leaving  twenty- 
nine  cases  under  treatment.  The  striking  fact  is  the  number  of  recoveries. 
I  must  explain  that  the  "recovery  "  from  any  form  of  senile  insanity  need 
not  necessarily  be,  and  is  not,  as  a  matter  of  fact,  an  absolute  restoration 
to  vigor  of  mind.  Some  such  complete  recoveries  there  were,  men  who 
went  out  and  earned  their  own  livelihood,  Avomen  who  went  out  and 
governed  their  households.  But  such  cases  were  usually  the  short 
attacks  of  exaltation  or  depression  that  I  have  referred  to.  They  mostly 
occurred  between  the  ages  of  60  and  75,  though  they  were  not  absolutely 
unknown  after.  At  least  one-half  of  the  recoveries,  perhaps  rather  more, 
were  returns  to  or  gradual  passings  into  comfortable,  manageable,  normal 
senility.  That  is  all  that  can  be  expected  in  a  case  with  the  typical 
characters  of  senile  insanity.  It  is  all  I  ever  lead  the  relations  to  expect 
will  occur.  But  it  is  a  most  happy  change  from  senile  mania.  To  have 
an  aged  father  or  mother  pass  out  of  such  a  condition,  and  become  fit  to 
go  home  and  be  lovingly  cared  for  till  death  takes  place,  is  an  occurrence 
for  which  most  persons  of  proper  feeling  will  be  profoundly  grateful. 
When  such  a  return  to  normal  senility  occurs,  there  is  usually  little 
tendency  for  the  excitement  to  return  under  proper  care  and  feeding. 

The  recovery  rate  in  each  quinquenniad  from  60  to  75  was  about  the 
same,  and  the  rate  in  that  whole  period  of  fifteen  years  was  36  per  cent., 
or  60  cases  out  of  165.  The  numbers  in  each  of  the  next  quinquenniads 
were  too  small  to  give  results  worth  generalizing  on,  but  the  total  number 
of  recoveries  in  the  thirty-eight  cases  over  the  age  of  75  was  twelve,  or  at 
the  rate  of  32  per  cent.  This  last  was  one  of  the  results  that  surprised 
me,  I  confess. 

The  recoveries  took  place  in  about  the  usual  time  that  recoveries  from 
other  forms  of  insanity  take  place.  About  one-half  (47  per  cent.)  of 
them  were  discharged  recovered  within  three  months  of  residence,  and 
over  three-fourths  (79  per  cent.)  of  them  within  six  months.  In  fact, 
rather  a  larger  number  recovered  within  six  months  than  the  average 
recoveries  in  an  asylum. 

Sixty -nine  of  the  203  cases  have  died  up  to  this  time.  There  is  much 
risk  of  them  dying  within  the  first  month ;  this,  of  course,  meaning  that 
in  a  considerable  number  of  cases  the  mental  disease  is  of  the  nature  of 
an  ante-mortem  delirium,  like  L.  C.'s  case  I  have  related.  Seven  per 
cent,  of  the  cases  died  within  the  first  month,  making  about  20  per  cent, 
of  the  whole  of  the  deaths.     Far  more  died  in  the  first  than  in  any  sub- 


406  SENILE    INSANITY. 

sequent  month.  More  than  half  the  deaths  occurred  within  the  first  six 
months  of  residence,  that  being  a  considerably  earlier  period  of  death 
than  occurs  in  most  other  forms  of  insanity. 

Pathology  of  Senile  Insanity. — The  pathology  of  the  disease  is 
interesting  because  it  has  some  approach  to  definiteness.  It  is,  next  to 
general  paralysis,  the  form  of  mental  disease  in  which  the  most  distinct 
pathological  appearances  are  found  in  the  brain.  Out  of  the  ninety-two 
deaths  we  were  allowed  to  have  post-mortevi  examinations  in  fifty-two 
cases.  I  often  find  it  unusually  difficult  to  obtain  permission  for  post- 
mortem examinations  in  senile  cases.  An  exhaustive  analysis  of  the 
pathological  appearances  found  in  these  fifty-two  cases  would  be  far  too 
tedious  to  attempt.  Many  of  the  cases  would  need  a  special  description 
to  do  them  justice.  All  I  shall  attempt  is  a  summary  of  the  chief  ap- 
pearances. The  most  common  of  all  the  lesions  found  in  the  brain  itself 
was  that  form  of  combined  cerebro-vascular  disease,  commonly  called 
softening  of  the  brain.  This  occurred  in  a  marked  form  in  twenty-two 
cases,  or  forty-two  per  cent,  of  the  whole.  I  need  hardly  say  that  I  use 
the  term  in  the  proper  sense  of  a  ramolh'ssement,  a  localized  necrosis, 
partial  or  entire,  of  a  portion  of  brain  tissue,  resulting  in  most  cases  from 
a  deprivation  of  blood  through  embolism  or  thrombosis  of  the  arterial 
branches  supplying  it.  In  every  case  of  softening  there  was  marked 
vascular  disease,  and  in  many  cases  the  obstructed  vessel  that  had 
formerly  supplied  the  starved  portion  of  brain  could  be  demonstrated. 
Commonly  the  form  of  vascular  disease  was  atheroma  in  an  advanced 
form,  sometimes  aneurisms,  large  and  small,  sometimes  inflammatory 
general  thickening  of  the  coats  of  the  vessels.  The  softenings  were  com- 
monly localized  and  seldom  very  extensive,  in  this  differing  markedly 
from  the  softening  found  in  the  brains  of  younger  insane  persons.  They 
were  found  everywhere,  but  the  most  common  sites  were  the  great  basal 
ganglia,  notably  the  corpus  striatum,  and  the  convolutions  of  the  vertex 
and  lateral  portions  of  the  anterior  and  middle  lobes.  The  appearances 
of  the  vsoftenings  were  very  different  in  different  cases,  according  to  their 
duration  and  the  sudden  or  gradual  onset  of  the  lesion.  When  a  twig  of 
a  cerebral  artery  is  suddenly  obstructed  by  an  embolic  plug,  most  of  the 
tissue  supplied  by  it  dies  at  once,  a  sort  of  inflammatory  process  (the 
"red  softening"  of  the  older  pathologists)  taking  place  for  a  few  days 
first.  Then  it  liquefies  from  the  centre  outwards,  appearing  as  the  typical 
"white  softwiing,"  the  process  usually  tending  to  spread  into  the  sound 
tissue,  but  sometimes,  if  the  dead  portion  is  very  small,  the  debris  gets 
partly  absorbed  and  the  tissue  round  it  sacculates,  or,  in  still  rarer 
instances,  shrinks  together,  forming  a  condensed  cicatrix-looking  spot. 
But  no  doubt  the  common  thing  is  slow  progression  of  the  softening,  in 
accordance  with  that  fatal  law  of  progressive  nerve-tissue  degeneration 
first  described  by  Waller  in  the  peripheral  nerves,  and  which  has  since 
been  found  to  exist  in  so  many  nervous  diseases.  In  senile  cases  the 
softening  process  is  commonly  gradual  through  the  slow  starvation  of  an 
area  of  brain  tissue  from  a  gradual  atheromatous  diminution  of  the  lumen 
of  its  supplying  vessel.  I  did  not  at  one  time  believe  in  a  non-syphilitic 
senile  arteritis  affecting  all  the  coats  of  the  vessels.  Now  I  do,  for  I  have 
seen  it.     And  I  know  of  no  test  to  distinguish  such  arterial  disease  from 


SENILE    INSANITY.  407 

the  more  common  syphilitic  arteritis.  In  that  case  there  is  no  preliminary 
red  softening,  but  a  slow  absorption  of  the  nervine  tissue,  a  corresponding 
compensatory  development  of  the  less  vitalized  neuroglia  and  packing  and 
retaining  tissues  generally,  giving  the  appearance  at  first  of  a  spongy  gray 
area,  and  going  on  to  its  complete  atrophy  and  disappearance.  The  ap- 
pearance caused  by  the  sudden  and  the  gradual  starvation  process  differs 
much  in  the  convolutions  and  the  white  substance.  The  former  having 
about  five  times  the  blood-supply  of  the  latter,  it  is  far  more  apt  to  be 
filled  with  hemorrhagic  debris  in  the  sudden  cases,  and  to  have  a  gray, 
dirty,  gelatinous  look  in  the  gradual  cases.  The  convolutions  or  parts  of 
convolutions  affected  look  wasted,  the  pia  mater  comes  off  readily,  and  to 
the  touch  their  resistance  is  very  soft.  It  is  difficult  even  to  harden  them 
in  spirit.  The  chief  blood-supply  of  the  convolutions  being  derived  from 
small  arterial  twigs  from  the  pia  mater,  each  twig  not  anastomosing  much 
with  the  others,  but  nourishing  a  small  convolutional  area  of  its  own,  if 
one  of  these,  is  obstructed  its  area  dies  and  softens,  slowly  or  quickly, 
according  to  the  kind  of  obstruction.  But,  as  Duret  and  Heubner  show, ' 
the  convolutions  have  a  second  blood-supply  from  within.  We  do  not 
find  the  complete  necrosis  of  tissue  in  the  gray  that  is  found  in  the  white 
substance.  The  former  always  retains  some  vitality,  and  seldom  becomes 
a  liquid  pulp,  or  altogether  disappears,  like  the  white  substance,  from  this 
cause. 

The  next  notable  appearance  observed  was  marked  atrophy  of  the 
whole  brain,  or  of  considerable  portions  of  its  convolutional  surface. 
This  existed,  alone  or  in  conjunction  with  other  lesions,  in  so  marked  a 
degree  as  to  be  put  down  as  one  of  the  direct  causes  of  death  in  twelve 
cases,  and  in  a  lesser  degree  in  most  of  the  others.  No  doubt  this  atrophy 
is  partly  the  same  process  as  softening,  only  the  starvation  process  is 
slower  still,  and  is  partly  owing,  not  to  a  diminished  blood-pabulum 
merely,  but  to  an  innate  lack  of  trophic  energy  in  the  neurine  elements. 
It  manifests  itself  in  brain  sections  by  much  enlarged  perivascular  canals 
and  dilated  ventricles.  The  curious  way  in  which  the  cerebral  envelopes 
and  packing  elements  seem  to  make  an  effort  to  expand  and  compensate 
in  bulk  for  the  shrinking  brain  is,  I  suppose,  partly  connected  with  the 
physical  conditions  of  the  closed  box  within  the  cranium,  inaccessible  to 
the  atmospheric  pressure  except  through  the  bloodvessel  openings  and 
the  foramen  magnum ;  and  partly  owing,  no  doubt,  to  the  congestions  of 
the  whole  of  the  tissues  supplied  by  the  carotid  arteries  and  their  branches 
that  accompany  the  paroxysms  of  maniacal  excitement.  From  whatever 
cause,  when  the  brain  is  most  atrophied  we  are  most  apt  to  have  thicken- 
ings of  the  skull-cap,  often  taking  the  form  of  successive  layerings  of 
bone  over  the  inner  table  where  it  covers  the  vertex,  and  especially  over 
the  anterior  lobes,  where  the  atrophy  is  usually  most  marked.  The  dura 
mater  is  commonly  thickened,  and  usually  adheres  pretty  strongly  to  the 
skull-cap.  The  arachnoid  is  thickened,  the  pia  mater  thick  and  fibrous, 
and  the  cerebro-spinal  fluid  superabundant,  milky,  and  full  of  microscopic 
debris. 

There  were  recent  apoplexies  of  such  a  size  as  to  be  seen  by  the  naked 
eye  in  only  five  cases.  Microscopic  apoplexies  within  the  pia  mater,  in 
the  tissues  and  round  the  softenings,  and  in  the  perivascular  canals,  are 


408  SENILE    INSANITY. 

much  more  frequent.  In  fact,  there  are  few  cases  of  senile  maniacal 
excitement  in  which  such  apoplexies  cannot  be  found  in  these  positions. 
But  among  all  those  cases  of  softening  it  seems  marvellous  that  there 
were  not  more  cases  of  apoplexy.  Given  vessels  with  weak,  diseased, 
and  inelastic  coats,  given  atrophy  and  softening  of  the  brain,  the  place  of 
the  solid  tissue  being  taken  by  mere  liquids  and  spots  of  softening,  and 
add  to  these  maniacal  attacks  implying  intense  vascular  congestion,  one 
would  think  that  large  apoplexies  must  occur  in  every  case  from  the  want 
of  support  to  the  diseased  vessels.  Yet  we  have  seen  this  was  seldom  the 
case.  The  existence  of  small  apoplexies  probably  explains  the  occurrence 
of  transient  attacks  of  hemiplegia,  as  in  a  very  interesting  senile  case  in 
this  asylum  reported  by  Dr.  J.  J.  Brown,^  in  which  the  whole  of  the  pia 
mater  was  full  of  miliary  aneurisms,  and  most  of  the  convolutions  filled 
with  pin-point  apoplexies.  Such  cases,  as  well  as  the  cases  with  limited 
softenings,  bring  senile  insanity  into  close  relationship  pathologically  with 
paralytic  insanity,  with  which  it  has  many  common  features.  They  are 
the  two  clinical  forms  of  insanity  most  allied.  Senile  insanity  often  be- 
comes paralytic  insanity.  Paralytic  insanity  always  has  many  of  the 
mental  symptoms  of  senile  insanity. 

There  was  distinct  meningitis  in  three  cases,  one  of  which  was  the  case 
of  L.  E.,  with  "pachymeningitis  hsemorrhagica  externa,"  referred  to  on 
page  402.  Of  the  other  organs  of  the  body,  the  heart  was  found  most 
frequently  afiected,  there  being  marked  cardiac  disease  in  ten  cases.  The 
lungs  came  next,  with  bronchitis  and  broncho-pneumionia  in  nine  cases ; 
and  next  the  kidneys  in  two  cases.  In  many  of  the  patients  several  of 
the  above  morbid  conditions  were  combined. 

With  regard  to  the  microscopic  appearances  in  senile  brains,  I  must 
refer  to  the  careful  and  correct  descriptions  and  drawings  of  Dr.  Major.^ 
We  have  all  been  able  to  confirm  those  observations,  and  perhaps  to  see 
some  special  points  in  addition,  but  have  not  been  able  to  add  much  to 
them.  The  various  stages  in  the  degeneration  of  the  large  cells,  the 
atrophy  of  the  smaller  cells  and  nuclei,  the  enlargement  of  the  vascular 
canals,  and  the  debris  of  granules  and  hsematin  crystals,  are  all  well 
described  by  Dr.  Major.  I  have  met  with  such  general  atrophy,  as  is 
represented  in  Plate  VIII.  Fig.  3,  in  several  cases  in  which  the  nerve-cells 
and  fibres  were  gradually  disappearing,  leaving  only  an  irregular  loose 
reticulation  of  cell-walls,  neuroglia,  and  atrophied  vessels. 

The  weak  point  in  the  pathology  of  senile  insanity  is  that  we  have  no 
means  of  comparing  those  lesions  and  changes  I  have  described  with  the 
appearances  of  the  brains  of  old  persons  who  were  not  insane.  Beyond 
a  doubt,  some  of  them,  both  naked-eye  and  microscopic,  are  present  in 
persons  whose  mental  condition  never  got  beyond  normal  senility ;  but 
there  is  less  doubt  that  in  the  brains  of  fifty-two  persons  from  the  average 
population  over  sixty,  there  would  not  have  been  found  so  many  soften- 
ings and  atrophies,  etc.  What  we  have  to  ask  ourselves,  in  order  to  form 
anything  like  a  proper  conception  of  these  cases  of  senile  insanity,  is, 
what  was  the  relationship  between  the  purely  dynamical  phenomena  of 

^  Journal  of  Mental  Science,  Jul}',  1874. 

"  West  Kiding  Keports,  vol.  ix.  p.  223  ;  and  Ibid.,  vol.  v.  p.  161, 


SENILE    INSANITY.  409 

morbid  mental  exaltation  or  depression,  loss  of  memory,  and  constant 
purposeless  motor  excitement,  during  life,  and  the  atrophied  convolutions, 
the  degenerated  cells,  the  diseased  vascular  system,  and  the  starved  areas 
of  brain  found  after  death  ?  Did  these  pathological  changes,  when  they 
advanced  to  a  certain  point,  simply  allow  old  hereditary  convolutional 
weaknesses  to  come  out  that  had  been  so  slight  that  by  nothing  but  slow 
death  of  brain  tissue  could  they  have  become  actualities  instead  of  mere 
potentialities  ?  Or  had  the  advancing  brain  degeneration  simply  weak- 
ened and  destroyed  all  the  higher  inhibitory  faculties  and  "centres"  in 
the  brain?  Is  the  constant  motor  restlessness  referable  to  the  progress 
of  the  manifest  changes  in  the  larger  "motor"  cells  of  the  convolutions? 
Is  the  loss  of  memory  a  mere  paralysis  of  the  power  of  attention  and 
mental  concentration  on  sense  impressions — a  result  of  the  loss  of  inhibi- 
tory power,  in  fact  ?  Or  is  it,  in  addition,  an  absolute  paralysis  of  recep- 
tive capacity  on  the  part  of  the  cells  in  the  convolutions,  the  impressions 
from  the  senses  being  "writ  in  water"?  Or  do  the  impressions  not 
reach  the  convolutions  through  degeneration  of  the  white  conducting 
fibres  ?  As  to  the  memory  of  old  events,  which  is  the  last  to  go,  is  that 
just  the  result  of  destruction  and  atrophy  of  the  cells  as  organized  activ- 
ities ?  What  light  does  the  whole  known  pathology  throw  on  the  constant 
connection  of  the  mental  and  motor  symptoms  ?  It  seems  to  me  that 
that  connection  in  senile  insanity  is  another  proof  of  the  motor  functions 
of  some  of  the  brain  convolutions. 

How  can  senile  insanity  best  be  treated  and  managed  ?  I  can  only  lay 
down  the  principles  that  I  have  found  useful,  and  can  scarcely  enter  into 
the  details  of  individual  cases  or  requirements.  The  thing  of  first 
importance  is  undoubtedly  to  get  a  good  nurse — a  responsible,  skilled, 
patient,  experienced  person. .  Women  make  by  far  the  best  nurses  for  old 
people  of  either  sex,  but  for  male  patients  they  are  sometimes  not 
physically,  strong  enough.  After  a  good  nurse  (and  a  daughter  or  rela- 
tive will  sometimes  make  the  best  of  all)  comes  the  routine  of  management, 
diet,  exercise,  and  regimen.  Excitement,  and  new  things  or  ways,  or 
places  or  persons,  should  be  avoided.  Old  people  take  best  with  what 
they  have  been  accustomed  to.  Warmth  by  day  and  night  is  most 
important,  combined  with  airiness  of  the  apartments.  The  clothing 
should  be  warm  by  night  as  well  as  by  day.  Cold  aggravates  excitement 
and  causes  dirty  habits.  The  night  management  is  the  most  important 
and  the  most  troublesome.  It  is  better  not  to  attempt  to  keep  the 
patients  in  bed  all  the  time  if  they  will  not  stay  there  quietly.  Struggling 
with  them  causes  irritation  and  resistance.  A  suite  of  airy,  not  over- 
furnished  apartments  down  stairs  are  the  best.  As  to  exercise  in  the 
fresh  air,  it  is  most  important.  It  makes  all  the  difierence  between  being 
able  to  manage  a  case  at  home  at  all  or  to  manage  it  Avell  in  an  asylum. 
It  should  not  be  given  up  to  the  point  of  exhaustion,  like  exercise 
in  young  acutely  maniacal  cases.  The  walks  should  be  short  and  often  ; 
and,  when  the  weather  admits,  sitting  in  the  open  air  should  be  practised. 
Senile  patients  have  a  provoking  habit  of  sleeping  during  the  day  and 
waking  at  night.  Better  sleep  by  day  than  not  at  all.  The  diet  is  also 
most  important.  I  find  the  first  food  of  man  to  be  the  best  at  the  oppo- 
site end  of  life.     There  is  nothing  like  milk,  given  warm  and  in  small 


410  SENILE    INSANITY. 

quantities  at  a  time,  and  often.  Fatten  your  patient  and  you  will  improve 
him  in  mind.  Too  much  flesh  and  beef-tea  are  often  too  stimulating  and 
indigestible ;  cod-liver  oil  often  works  wonders,  and  so  does  maltine. 
Fresh  vegetables,  or  their  juice  in  soups,  should  always  be  given.  All 
the  solid  food  should  be  minced  or  pounded  for  a  large  number  of  the 
cases. 

Sometimes  it  is  necessary  to  fit  up  a  special  room  in  a  private  house  for 
night  use,  without  furniture,  warmed,  and  that  can  be  cleansed  daily. 
Night-feeding  as  well  as  day-feeding  is  often  needed.  Often  a  big 
stomachful  of  hot  porridge  or  bread  and  milk  will  give  a  night's  sleep  far 
better  than  a  hypnotic  medicine. 

The  purely  medical  treatment  is,  in  senile  insanity,  the  least  important, 
but  we  can  do  something  in  that  way.  My  experience  of  opium  is 
unfavorable  as  a  sedative.  It  diminishes  the  appetite,  and  often  kills  the 
patient.  But  by  means  of  mild  doses  of  the  bromides,  with  or  without 
small  doses  of  cannabis  Indica,  used  occasionally  as  required,  we  can  tide 
over  bad  nights  comfortably.  Tonics  are  useful,  and  iron  and  the  phos- 
phates often  work  wonders.  Alcoholic  stimulants  are  often  useful,  but 
not  so  often  as  is  commonly  supposed.  The  bowels  should  be  regulated 
by  the  simplest  laxatives,  some  treacle  or  syrup  given  with  the  evening 
meal  of  porridge  being  often  all  that  is  needed. 

The  great  aim,  in  most  patients,  is  to  get  into  comfortable  normal 
senility  as  soon  and  quietly  as  possible.  In  some  the  restlessness  and 
noise  are  so  pathological  that  nothing  seems  to  have  any  effect  in  con- 
trolling or  abating  them.  The  patient  and  his  brain  simply  wear  them- 
selves out,  and  everyone  about  him  is  thankful  when  all  is  over  without 
accident.  Few  questions  are  so  difficult  to  determine  as  the  one  of  send- 
ing a  very  old  person  to  an  asylum  or  not.  The  feelings  of  everyone  go 
against  it  if  there  are  a  good  home,  dutiful  relatives,  and  sufficient  means. 
The  best  way  is  to  try  all  other  means  first.  In  good  asylums  we  give 
the  poor  suffering  from  senile  insanity  a  sort  of  treatment  that  the 
richest  often  cannot  get  at  home  for  any  price,  and  in  many  instances 
with  remarkable  success.  If,  therefore,  there  are  poverty  and  no  conveni- 
ences for  treatment,  one  cannot  hesitate  about  the  course  to  adopt. 

I  am  well  aware  of  the  imperfect  view  of  the  whole  senile  condition, 
bodily  and  mental,  that  a  physician  to  an  asylum  is  apt  to  get  from 
seeing  the  very  worst  cases  only.  His  picture  is  filled  in  with  very  black 
shadows.  To  keep  himself  right,  he  must  take  all  the  opportunities  he 
has  of  seeing  and  studying  senility  outside  of  an  asylum,  which  I 
habitually  do,  trying  to  look  at  it  with  a  medico-psychological  and  patho- 
logical eye.  I  never  see  an  old  man  who  fails  to  interest  me  from  that 
point  of  view.  I  wish  physicians  in  general  practice  who  have  to  meet 
the  smaller  emergencies  of  senility  would  put  their  observations  before 
the  world  more  than  they  do.  I  find  the  management  of  most  old  cases 
is  regarded  without  much  interest.  And  yet  what  a  field  of  psychological 
study,  to  be  able  to  watch  the  waning  minds  of  strong  men  and  subtile 
women  ? 


LECTURE    XVIII. 

EARER  AND  LESS  IMPORTANT  CLINICAL  VARIETIES  OF  MENTAL 

DISTURBANCE. 

1.  ANEMIC  INSANITY.  2.  DIABETIC  INSANITY.  3.  INSANITY  FROM 
BRIGHT'S  DISEASE.  4.  INSANITY  OF  OXALURIA  AND  PHOSPHATURIA. 
5.  THE  INSANITY  OF  CYANOSIS  FROM  BRONCHITIS,  CARDIAC  DISEASE, 
AND  ASTHMA.  6.  METASTATIC  INSANITY.  7.  POST-FEBRILE  IN- 
SANITY. 8.  INSANITY  FROM  DEPRIVATION  OF  THE  SENSES.  9.  THE 
INSANITY  OF  MYXEDEMA.  10.  THE  INSANITY  OF  EXOPHTHALMIC 
GOITRE.  11.  THE  DELIRIUM  OF  YOUNG  CHILDREN.  12.  INSANITY 
OF  LEAD-POISONING.  13.  POST-CONNUBIAL  INSANITY.  14.  THE 
PSEUDO-INSANITY   OF   SOMNAMBULISM. 

In  addition  to  the  more  common  clinical  varieties  of  mental  disease, 
there  are  a  great  number  of  others  rarer,  but  of  much  interest  and  in- 
structiveness.  Most  of  them  are  etiological  vai'ieties,  but  there  are  some 
forms  in  which  the  mental  affection  must  be  considered  an  essential  part 
of  the  disease,  as  in  myxoedema.  I  cannot  enter  fully  into  any  of  these 
forms,  but  I  shall  glance  at  some  of  them  that  have  come  under  my  own 
observation. 

1.  Anjemic  Insanity. — There  are  a  few  cases  of  mental  disease  due 
to  anaemia  of  the  brain  from  starvation,  chlorosis,  or  prolonged  indiges- 
tion, or  some  other  causes  of  anaemia.  We  had  in  the  Royal  Asylum 
fifteen  of  those  out  of  the  3145  in  the  nine  years  1874—82.  Two-thirds 
of  these  fifteen  were  cases  of  melancholia,  and  the  rest  acute  mania. 
Eighty  per  cent,  of  them  recovered.  This  Avas  one  of  those  who  did  not: 
L.  H.,  get.  29,  of  a  quiet  and  reserved  disposition,  and  temperate  habits. 
No  neurotic  heredity  known.  He  had  had  no  work  and  little  food  for 
some  time  before  coming  into  the  asylum,  and  had  become  weak,  anaemic, 
and  run  down.  He  then  got  restless,  sleepless,  and  unsettled,  and  next 
melancholic,  attempting  to  go  over  a  window.  Then  he  became  acutely 
maniacal.  He  was  utterly  exhausted  in  strength,  though  acutely  mani- 
acal when  he  came  into  the  asylum.  The  maniacal  condition  alternated 
with  depression,  fearfulness,  fits  of  weeping,  and  partial  consciousness, 
saying  he  "  did  not  mean  to  do  any  harm."  He  was  fed  up,  but  he 
became  demented  and  incurable  very  soon.  Most  of  the  cases  were  mild 
melancholia,  some  of  them  having  an  element  of  stupor,  and  those  nearly 
all  recovered  within  three  months  under  good  feeding,  fresh  air,  and 
quinine  and  iron. 

2.  Diabetic  Insanity. — I  have  met  with  two  cases  in  which  melan- 
cholia was  associated  with  diabetes  mellitus.     Both  were  cases  of  melan- 


412  DIABETIC    INSANITY. 

cholia,  looked  at  from  a  symptomatological  point  of  view.  It  is  much 
the  same  to  the  practitioner  of  medicine  how  a  case  is  classified,  so  long 
as  the  classification  sheds  new  clinical  light  on  its  nature  and  causation. 
The  mental  condition  of  diabetic  patients  has  attracted  the  attention  of 
clinicists,  but  not  so  much  as  it  deserves.  We,  whose  practice  lies  chiefly 
in  mental  diseases,  are  often  accused  of  seeing  nothing  but  the  mental 
symptoms  of  our  cases  ;  but  we  have  good  reason  to  complain  of  the  way 
in  which  the  mental  symptoms  of  ordinary  diseases  are  overlooked  or 
neglected  by  general  physicians.  The  psychology  of  most  bodily  diseases 
has  yet  to  be  written,  and  one  has  a  faint  hope  that  the  clinical  study  of 
mental  diseases  by  students  of  medicine  may  so  familiarize  their  minds 
with  mental  symptoms  that  they  will  be  more  on  the  alert  to  look  for  them 
in  their  ordinary  practice  than  they  would  otherwise  have  been.  When 
they  are  looked  for  by  those  who  know  how  to  observe  and  name  them, 
they  will  be  found.  The  whole  history  of  medicine  is  one  long  tale  of 
finding  things  when  they  were  looked  for. 

The  first  case  was  that  of  L.  K.,  set.  59,  a  lady  who  has  held  an  offi- 
cial position,  working  hard  for  many  years.  Never  insane  before,  and  no 
heredity  to  the  neuroses.  Her  disease  showed  itself  by  mental  depression, 
irritability,  incapacity  for  work,  a  lack  of  interest  in  anything,  and  an 
indecision  of  character  quite  foreign  to  her,  all  these  symptoms  following 
a  carbuncle  on  the  occiput.  I  was  consulted  about  her,  and  discovered 
she  had  diabetes  mellitus,  which  had  existed  probably  for  a  year  before 
the  mental  symptoms  came  on.  She  had  no  appetite,  could  not  be  got 
to  take  enough  food,  and  what  she  did  take  seemed  to  do  her  no  good. 
She  had  the  usual  bodily  symptoms  of  diabetes — thirst,  frequent  mictu- 
rition, sugar  in  urine,  thinness,  and  dry  skin.  On  account  of  the  diffi- 
culty of  getting  her  to  take  enough  food,  to  dress  herself,  to  go  out  to 
walk,  as  well  as  her  noise  and  restlessness  at  night,  she  was  sent  to  the 
Royal  Asylum  about  three  months  after  the  depression  began.  The  usual 
treatment  was  adopted  for  the  diabetes,  but  with  no  avail.  Her  mental 
energy  got  enfeebled,  until  she  was  entirely  languid,  with  no  volitional 
power.  She  had  the  delusion  that  she  was  ruined,  and  could  not  pay  her 
debts.  The  only  thing  she  did  was  to  keep  up  a  continual  wail  by  day 
and  night.  The  temperature  was  98°  in  the  morning  and  98.4°  in  the 
evening.  She  became  steadily  weaker,  and  was  giddy  when  she  stood 
up,  and  towards  the  end  became  sleepy  all  the  time.  Her  urine  was 
never  very  copious,  and  its  specific  gravity  was  always  about  1080.  She 
had  a  small  ulcerated  spot  on  her  ankle,  which  could  not  be  healed,  and 
increased  slowly  in  size.  She  died  rather  suddenly  six  weeks  after  ad- 
mission. 

On  post-mortem  examination,  we  found  the  scalp  and  skull-cap  of  a 
yellowish  hue.  The  inner  table  of  the  skull-cap  was  irregularly  thick- 
ened by  bony  masses ;  the  dura  mater  was  leathery ;  the  pia  mater  was 
thickened,  and  could  be  removed  from  the  convolutions  with  abnormal 
ease.  The  convolutions  and  brain  generally  were  much  atrophied,  com- 
pensatory fluid  taking  its  place.  The  convolutions  stood  out  thin,  small, 
loosely  packed,  and  wedge-shaped.  The  fornix  and  corpus  callosum  were 
pale  and  soft.  The  lining  membranes  of  the  ventricles  were  roughened, 
with  a  trace  of  granulations.     Sections  of  the  brain  showed  an  irregular 


DIABETIC    INSANITY.  41eS 

mottling  of  a  pink  hue,  and  pallor  of  the  gray  substance  of  the  convolu- 
tions. The  whole  of  the  cerebral  substance  exhibited  a  loss  of  consist- 
ence, and  in  the  left  corpus  striatum  there  Avas  a  small  localized  softening, 
the  size  of  a  split  pea.    The  encephalon  only  weighed  thirty-eight  ounces. 

Dr.  Campbell  Clark  made  some  sections  of  the  medulla  for  me,  and 
they  all  show  (1)  great  looseness  of  texture,  (2)  localized  atrophies,  (3) 
abnormally  enlarged  perivascular  canals,  (4)  degenerated  and  partially 
atrophied  cells,  very  many  of  which  have  undergone  fuscous  degenera- 
tion, their  processes  having  largely  disappeared,  like  the  cells  in  senile 
dementia  (Plate  VIII.  Fig.  4).  On  the  whole,  therefore,  the  pathology 
of  diabetic  insanity,  so  far  as  that  case  throws  light  on  it,  seems  to  be 
an  innutrition  and  general  atrophy  of  the  brain,  especially  affecting  its 
convolutions. 

The  following  was  another  case:  L.  J.,  set.  57.  Classical  education  ; 
no  profession.  Temperament  melancholic.  Disposition  gloomy,  variable, 
and  excitable,  implying  the  nervous  diathesis.  Habits  steady,  industrious, 
especially  fond  of  figures.  First  attack.  Paternal  uncle  insane.  Causa- 
tion, work  and  worry.  One  particular  piece  of  business  was  the  exciting 
cause  of  his  first  mental  depression,  and  of  the  fancies  that  he  was  ruined. 
He  became  restless  and  sleepless,  and  could  talk  of  nothing  but  this.  He 
got  worse,  and  tried  to  starve  himself,  fancying  that  he  could  not  pay  for 
his  food,  and  had  therefore  no  right  to  eat  it.  Talked  of,  but  did  not 
attempt,  suicide.  When  I  saw  him,  eighteen  months  after  the  beginning 
of  his  illness,  he  was  much  depressed,  somewhat  stupid,  very  obstinate 
and  resistive,  and  looked  as  if  absorbed  in  his  own  morbid  ideas.  Gets 
a  little  irritable  and  subacutely  excited  when  pressed  to  speak  or  to  take 
food.  Attention  much  impaired ;  memory  seems  good  as  to  distant 
events.  He  has  the  delusions  that  he  is  ruined,  that  he  has  no  money, 
that  he  should  eat  nothing  because  it  cannot  be  paid  for.  His  countenance 
is  haggard,  depressed,  and  vacant ;  skin  cold  and  clammy ;  muscularity 
flabby  ;  fatness  is  deficient ;  pupils  equal  and  contractile ;  motor,  sensory, 
and  reflex  functions  normal;  lungs  and  heart  normal,  but  circulation 
weak ;  tongue  furred ;  bowels  costive ;  no  appetite ;  pulse  108,  weak ; 
temperature  99.8°.     Unfortunately  the  urine  was  not  examined  at  first. 

He  ate  only  on  great  pressure,  and  he  got  no  fatter.  His  skin  became 
dry  and  harsh  feeling.  Mentally  he  remained  doggedly  and  unreasonably 
obstinate  as  to  dressing,  undressing,  going  out,  and  especially  as  to  taking 
his  food.  He  read  a  little,  and  would  sit  by  the  hour  making  long  calcu- 
lations, showing  how,  at  the  rate  he  was  eating,  all  the  food  in  the 
country  would  soon  come  to  an  end.  Sometimes  he  would  say  he  was 
being  starved.  He  had  no  hallucinations.  He  had  one  or  two  small 
abscesses,  which  became  ulcers,  on  his  toes  that  would  not  heal.  He  was 
occasionally  dirty. 

He  was  treated  with  quinine,  iron,  the  phosphates,  phosphoms  pills, 
cod-liver  oil  and  the  hypophosphites,  maltine,  milk,  cream,  strychnine, 
vegetable  bitters,  and  the  mineral  acids  in  succession  or  combination. 
He  was  sent  for  change  of  air  to  the  asylum  sea-side  house  in  the  summer. 
Sometimes  temporary  improvement  took  place,  but  he  fell  off  and  got 
thinner  on  the  whole.  He  certainly  could  not  have  passed  as  much  water 
as  an  ordinary  diabetic  or  it  would  have  been  observed,  but  it  was  not  till 


414  INSANITY    OF    BRIGHT's    DISEASE 

near  the  end  of  his  life,  two  and  a  half  years  after  the  beginning  of  his 
illness,  that  his  urine  was  examined,  at  Dr.  Begbie's  request,  and  found 
to  be  loaded  with  sugar.  He  frequently  saw  him  with  me  in  consulta- 
tion, but  diabetes  had  never  been  suspected  till  towards  the  end  of  his 
life.  He  died  suddenly  of  exhaustion,  two  years  and  eight  months  from 
the  time  of  his  attack.  No  post-mortem  examination  in  this  case  was 
allowed. 

These  two  cases  of  diabetes  have  many  mental  symptoms  in  common, 
though  they  had  some  diiferences.  They  were  both  melancholic.  They 
both  imagined  they  had  no  money,  and  Avere  ruined,  and  could  not  pay 
their  debts.  They  both  had  a  disinclination  to  take  food.  They  were 
both  wanting  in  affection  for  their  children.  They  both  were  thin  and 
weak.  They  both  had  a  tendency  to  sores  on  extremities,  with  small 
healing  power.  But  the  one  was  more  resistive  and  dogged  ;  the  other 
more  passive,  inattentive,  and  utterly  uninterested  in  anything  in  the 
world.     Death  in  both  cases  occurred  rather  suddenly. 

3.  Insanity  of  Bright's  Disease. — This  is  a  variety  of  mental 
derangement,  half  delirium  and  half  mania,  which  results  from  ursemic 
poisoning.  I  have  met  with  several  cases  of  this  disease.  Dr.  Wilkes* 
has  published  several  cases  of  this  kind,  and  Dr.  Grainger  Stewart  says 
he  has  also  seen  similar  cases.  It  usually  occurs  in  chronic  cases  of 
Bright's  disease,  with  contracted  kidneys,  where  there  have  been  enlarge- 
ment of  the  heart  and  a  tendency  to  dropsy  for  some  time,  and  where  the 
central  nervous  system  has  been  long  subjected  to  the  influence  of  imper- 
fectly purified  blood.  The  symptoms  present  are  mania  of  a  delirious 
kind,  with  extreme  restlessness,  delusions  as  to  persons  round  the  patient, 
an  absolute  want  of  fear  of  jumping  through  windows,  or  other  actions 
that  would  kill  or  injure.  The  symptoms  are  characterized  by  remissions, 
during  which  the  patient  is  quiet,  rather  composed  in  mind,  and  rational, 
but  very  prostrate  in  body.  One  of  my  cases  was  L.  L.,  a  man  of  fifty, 
with  a  family  history  of  insanity,  who  had  once  been  much  depressed  in 
mind  (but  was  not  sent  to  an  asylum)  after  a  fever.  He  seems  to  have 
had  heart  disease  for  many  years,  and  to  have  had  Bright's  disease  for  at 
least  two  or  three  years  previous  to  his  admission  into  the  asylum.  He 
had  dropsy  of  his  legs  for  some  weeks  before  the  mental  symptoms  began. 
He  was  at  first  morose  and  irritable  to  a  morbid  degree,  and  steadily  got 
worse  in  mind,  his  symptoms  changing  to  exaltation  and  excitement, 
fancying  he  could  do  wonders,  had  absurd  schemes  for  making  money, 
and  threatened  to  murder  everyone  near  him.  On  admission  he  was  in  a 
state  of  mental  exaltation  and  excitement,  gesticulating,  saying  he  had 
been  married  and  had  no  children  (which  were  delusions),  and  his  memory 
quite  gone.  His  speech  was  thick  and  indistinct,  his  tongue  coated,  his 
pupils  dilated,  and  slowly  sensitive  to  light,  the  reflex  action  of  the  cord 
dulled,  and  the  temperature  below  normal ;  legs  oedematous ;  his  lungs 
were  dull  at  bases;  his  heart  hypertrophied,  with  a  loud  murmur  with 
first  and  second  sounds;  urine  contained  much  albumen,  and  a  few  tube- 
casts,  sp.  gr.  1020.  This  man  alternated  between  this  state  of  mind  and 
that  of  a  drowsy,  stupid,   but  fairly  rational  condition,  till  two   days 

^  Journal  of  Mental  Science,  July,  1874. 


INSANITY    OF    OXALURIA    AND    PHOSPPI ATU  RI  A  .        415 

before  his  death,  when  he  got  semi-comatose,  with  periods  of  delirium. 
He  only  lived  five  weeks  after  admission,  or  about  two  months  from  the 
appearance  of  his  mental  symptoms.  This  is  a  typical  case  of  the  disease. 
No  doubt  the  mental  portions  of  his  brain  were  the  weak  points  of  his 
central  nervous  system  from  his  hereditary  predisposition  to  insanity,  and 
the  uraemic  poison  took  effect  there  instead  of  causing  convulsions. 

4.  Insanity  of  Oxaluria  and  Phosphaturia. — All  writers  on  the 
urine  have  noticed  the  hypochondriasis,  depression  of  mind,  want  of 
energy  and  originating  power,  and  the  irritability  that  so  often  go  along 
with  the  presence  of  much  oxalate  of  lime  or  phosphates  in  the  urine. 
Dr.  Prout'  thought  that  the  mental  state  was  probably  the  cause  of  these 
abnormal  products  in  the  urine,  and  he  especially  mentions,  "a  nervous 
state  of  the  system,  and  particularly  mental  anxiety  and  fear,"  as  causes 
that,  "will  frequently  produce  in  many  people  an  excess  of  the  salt  in  the 
urine."  Golding  Bird^  says  that  "persons  affected  with  'oxaluria'  are 
generally  remarkably  depressed  in  spirits,  hypochondriacal,  extremely 
nervous,  painfully  susceptible  to  external  impressions,  and  in  many  cases 
labor  under  the  impression  that  they  are  about  to  fall  victims  to  con- 
sumption." He  says,  in  reference  to  phosphaturia,  that  there  are  cases 
with  this  condition  characterized  by  high  nervous  irritability,  following 
injury  to  the  spine.  The  late  Dr.  Begbie  directed  special  attention  to 
oxaluria  as  a  cause  of  a  nervous  disorder,  which  was  characterized  by  a 
very  highly  neurotic  condition  of  the  patient.  He  says  such  patients  are 
commonly  in  the  prime  of  life,  belong  usually  to  the  upper  classes,  and 
have  indulged  freely  in  the  good  things,  especially  the  sweets  of  the 
table.  He  says  their  sufferings  often  threaten  their  mental  condition. 
•  "They  are  usually  peevish,  sensitive,  and  irritable,  or  dull  and  despond- 
ing, and  melancholic."  His  theory  of  the  causation  of  these  miseries  is, 
that  they  "  flow  from  the  oxalic  diathesis  from  a  poison  generated  during 
the  process  of  digestion  and  assimilation,  carried  into  the  blood  by  the 
ordinary  channels,  but  limited  in  its  pernicious  consequences  by  the  busy 
agency  of  the  urinary  organs  in  separating  it  from  the  circulation,  and 
discharging  it  from  the  system."  Several  of  the  cases  he  gives  were 
almost  insane,  but  I  fancy  few  such  require  asylum  treatment.  He 
shows  that  the  nervous  symptoms  are  apparently  a  result  of  the  oxaluria, 
and  disappear  under  the  treatment  that  cures  it.  There  is,  on  the  other 
hand,  no  doubt  of  the  fact  that  oxalates  may  be  found  in  very  great 
abundance  in  the  urine  of  persons  in  good  health.  Lehmann,  Bence 
Jones,  and  Garrod,  and  many  others,  direct  special  attention  to  this  fact. 
The  former,  along  with  many  other  physicians,  think  that  its  appearance 
is  not  at  all  essentially  connected  with  any  special  disease  or  train  of 
symptoms.  Speaking  generally,  the  chemical  physicians  who  have 
written  on  the  urine  take  this  view,  while  the  clinical  physicians  take  the 
opposite. 

In  a  very  considerable  number  of  a  certain  class  of  melancholies,  the 
irritable  hypochondriacs,  we  find  oxalates  or  basic  phosphates  in  the  urine, 
and  the  special  treatment  suitable  for  those  conditions  as  an  adjunct  to 
the  moral  and  tonic  treatment  of  the  melancholia  seems  certainly  to  be 

1  Prout  p.  176,  2d  ed.  "  G.  Bird,  pp.  2.50  and  307. 


416  POST-FEBRILE    INSANITY. 

useful.     I  think  there  is  scarcely  enough  evidence  to  show  whether  this 
condition  of  the  urine  is  a  cause  or  an  effect  of  the  brain  state. 

5.  The  Insanity  of  Cyanosis  from  Bronchitis,  Cardiac  Disease, 
AND  Asthma. — This  is  a  form  of  delirium,  with  confusion,  hallucina- 
tions of  sight,  sleeplessness,  sometimes  suicidal  impulses,  and  vague  fears. 
Those  symptoms  are  usually  worst  at  night,  and  often  end  in  mental 
torpor,  passing  into  coma.  It  is  more  commonly  seen  in  persons  of 
advanced  age  than  in  young  people.  In  some  degree  the  mental  power 
is  usually  affected  in  most  old  persons  who  have  diseases  that  prevent  the 
blood  being  properly  oxygenated.  No  doubt  a  hereditarily  weak  or  a  senile 
brain  suffers  more  than  a  stronger  brain  in  this  way. 

6.  Metastatic  Insanity. — The  typical  rheumatic  insanity  is  essen- 
tially a  metastatic  insanity,  the  diseased  process  leaving  the  joints,  its 
normal  seat,  and  attacking  the  nervous  centres.  I  have  seen  more  than 
one  case  where  the  healing  of  an  old  ulcer  was  followed  by  an  attack  of 
insanity.  I  have  seen  instances  of  erysipelas  of  the  face  "striking 
inwards"  and  causing  an  attack  of  acute  mania.  I  have  often  seen  the 
disappearance  of  a  syphilitic  psoriasis  followed  by  melancholia,  and  its 
reappearance  on  the  skin  precede  mental  recovery.    . 

7.  Post-febrile  Insanity. — The  next  form  of  insanity  I  shall  refer 
to  is  that  called  by  Dr.  Skae  post-febrile  insanity.  The  exhaustion  of 
the  vital  powers  that  is  caused  by  zymotic  diseases  sometimes  takes  special 
effect  on  the  higher  functions  of  the  brain,  and  we  have  an  attack  of  in- 
sanity resulting.  The  nervous  affections  that  often  follow  fevers  in 
children  are  well  known.  These,  no  doubt,  are  precisely  analogous  to 
the  post-febrile  insanity  of  the  adult.  The  insanity  which  sometimes 
followed  fevers,  was  known  from  the  earliest  times,  and  was  evidently 
much  more  common  two  hundred  years  ago  than  now,  but  it  was  then 
ascribed  not  to  the  exhausting  effects  of  the  fever,  but  to  its  not  having 
been  treated  with  "sufficient  dilution"  and  purges  to  carry  off  the  entire 
matenes  morbi,  thus  leaving  a  dangerous  element  in  the  system,  that  was 
liable  to  fly  to  the  head  and  cause  insanity.  Arnold  thought  that  insanity 
was  much  less  common  in  his  time  than  in  Sydenham's  after  fevers  and 
agues,  because  they  purged  more  than  the  old  physicians,  and  used  the 
Peruvian  bark  more  freely.  Post-febrile  insanity  is  not  specially  confined 
to  one  kind  of  fever. 

I  went  over  the  records  of  over  a  thousand  cases  of  insanity  that  were 
sent  to  the  Carlisle  Asylum,  and  I  found  that  among  those  there  had  been 
ten  cases  of  such  post-febrile  insanity,  four  of  which  followed  scarlet  fever, 
two  smallpox,  one  typhus,  one  typhoid,  one  intermittent,  and  in  the  tenth 
case  I  could  not  ascertain  the  exact  form.  Those  are  small  numbers  on 
which  to  base  any  conclusions  in  regard  to  a  disease,  but  I  am  not  aware 
of  any  fuller  statistics  on  the  subject.  I  think  those  numbers  represent 
in  a  general  way  the  comparative  frequency  of  its  occurrence  after  the 
different  fevers. 

Scarlatina  is  unquestionably  the  most  frequent  cause,  and  smallpox 
the  next.  It  is  said  to  follow  typhus  more  frequently  than  typhoid,  and 
as  intermittent  fever  is  now  very  infrequent  in  this  country,  this  is  a  very 
rare  cause  of  the  disease. 

Whether  this  represents  the  comparative  exhausting  powers  of  the 


POST-FEBRILE    INSANITY.  417 

poisons  of  those  fevers  on  the  brain,  or  whether  scarlatina  stands  at  the 
head  of  tlie  list,  from  its  greater  frequency,  or  from  its  more  common  oc- 
currence in  youth  -when  the  brain  has  not  attained  its  maturity,  I  am 
unable  to  say  with  certainty.  The  form  of  insanity  that  results  after 
scarlatina  is  almost  always  characterized  by  symptoms  of  dementia  which 
are  incurable. 

We  might  expect  this  from  the  well-known  occurrence  of  idiocy  and 
epilepsy  in  children  after  this  disease  of  sequelte  and  complications. 
More  frequently  than  after  any  other  fever  we  hear  the  remark — "Such 
a  person  has  never  been  the  same  since  he  had  scarlet  fever."  On  the 
whole,  I  think  there  is  fair  ground  for  the  assumption  that  the  poison  of 
this  disease  is  more  apt  to  leave  permanent  brain  disease  than  any  of  the 
others.  When  mental  symptoms  follow  the  disappearance  of  scarlatina, 
they  do  so  at  once ;  the  patient  not  having  an  attack  of  acute  excitement 
so  commonly  as  that  he  is  left  after  the  disease  in  a  state  of  partial  dementia. 
The  weakness  of  mind  is  not  complete,  but  more  of  a  partial  imbecility, 
a  blunting  of  all  the  mental  fiiculties  and  affections,  with  attacks  of  sub- 
acute excitement  and  irritability.  In  two  of  my  four  cases  there  was 
deafness  along  with  the  imbecility,  showing  that  the  effects  of  the  disease 
had  not  been  confined  to  the  brain  convolutions,  but  had  also  affected  the 
organs  and  centres  of  special  sensation. 

The  form  of  insanity  that  follows  smallpox  is  of  the  same  character  as 
that  of  scarlatina,  but  is  even  more  incurable.  That  of  typhus  and 
typhoid  is  more  clearly  the  result  of  brain  exhaustion  from  those  diseases 
in  cases  Avhere  they  have  continued  for  a  long  time.  The  patient  seems 
to  come  out  of  the  fever,  showing  no  particular  mental  symptom  or  in- 
sanity until  some  weeks  afterwards,  when  he  is  attacked  with  acute  ex- 
citement, or  "gets  into  a  Ioav  way,"  and  a  long-continued,  intractable 
depression  results.  Tuke  and  Bucknill  and  Maudsley  say  that  the  in- 
sanity that  follows  typhus  is  of  a  more  incurable  kind  than  that  resulting 
from  typhoid.  Sydenham  describes  the  form  of  insanity  that  used  to 
follow  ague,  and  in  his  time  this  seems  not  to  have  been  uncommon.  He 
calls  it  a  peculiar  form  of  mania,  and  says  that  the  long  continuance  of 
the  fever,  and  of  its  being  of  a  quartan  type,  seemed  to  produce  the  mental 
symptoms  more  than  any  other  circumstances.  If  treated  by  the  exhibi- 
tion of  strong  evacuants  it  degenerates  into  hopeless  fatuity.  My  single 
case  of  the  disease  was  that  of  a  sailor,  who  had  regular  attacks  of  ague, 
drank  hard,  lived  on  salt  provisions  during  his  voyage,  and  on  his  arrival 
had  an  acute  maniacal  attack.  He  was  thin,  pale,  and  slightly  scorbutic. 
I  treated  him  with  abundant  diet,  malt  liquors,  fresh  air,  quinine  and 
iron,  and  a  few  draughts  of  chloral  at  bedtime,  and  he  was  quite  well 
again  in  two  months,  having  gained  twenty  pounds  in  weight  in  that 
time.  In  this  case,  of  course,  there  were  the  other  causes  of  brain  ex- 
haustion as  well  as  the  ague. 

Of  my  ten  cases  only  the  above-mentioned  patient,  and  one  of  the 
scarlet  fever  patients,  had  acute  symptoms  of  any  sort,  and  they  were 
the  only  ones  who  recovered.  All  the  others  were  incurable,  six  of  them 
being  hopelessly  demented,  and  the  two  others  hopelessly  melancholic. 
There  was  hereditary  predisposition  to  insanity  in  only  three  of  the  ten 
cases. 


418       INSANITY    FROM    DEPRIVATION    OF    THE    SENSES. 

Post-febrile  insanity  may  be  said,  therefore,  to  be  generally  charac- 
terized by  subacute  symptoms,  to  result  from  the  brain  being  poisoned 
by  zymotic  poison  and  exhausted  by  fever,  not  to  require  a  hereditary 
tendency  for  its  development,  and  to  be  a  very  incurable  form  of  insanity 
from  the  beginning. 

I  once  met  with  a  peculiar  form  of  transient  mania  following  an  attack 
of  erysipelas  of  the  face  in  a  lady,  L.  M.,  Avho,  a  fortnight  before,  had 
been  attacked  with  erysipelas  of  the  head  and  face  of  a  very  severe 
character,  causing  much  swelling,  shutting  up  of  the  eyes,  and  being  ac- 
companied by  slight  delirium.  All  the  acute  symptoms  of  this  had  passed 
off,  the  temperature  was  down  from  104°  to  normal,  and  the  swelling  of 
the  face  was  abating,  but  still  she  could  not  open  her  eyes.  About  three 
days  before  I  saw  her  she  seemed  to  know  that  she  was  going  out  of  her 
mind,  for  she  asked  her  friends  to  keep  her  as  long  at  home  as  possible 
before  sending  her  away.  She  then  began  to  wander  in  mind,  and  to  have 
hallucinations  of  sight  and  hearing,  to  mistake  identities,  and  to  fancy 
she  had  a  child.  She  would  go  on  talking  to  imaginary  people,  would 
especially  keep  up  long  conversations  with  God,  would  ask  Him  quite 
familiarly  what  she  Avas  to  do  if  any  one  requested  her  to  take  medicine, 
etc.,  and  would  fancy  she  got  an  immediate  reply.  Her  amatory  pro- 
pensities were  exalted,  and  her  religious  feelings  and  emotions  were  both 
excited  and  perverted.  Usually  she  lay  in  bed,  but  was  at  times  very 
violent  indeed.  Her  pulse  was  86,  and  of  fair  strength,  and  her  tem- 
perature 98.6°.  She  slept  little.  She  took  liquid  food.  She  could 
open  her  eyes  slightly  and  with  difficulty,  but  seldom  did  so,  and  evi- 
dently preferred  to  keep  them  shut,  and  live  in  her  own  world  of  fancies. 
Her  state  much  resembled  a  waking  dream.  Impressions  on  her  senses 
of  hearing  and  touch  were  acutely  felt,  however,  and  made  much  im- 
pression often  in  diverting  her  from  her  unreal  beliefs  and  hallucinations. 

She  got  stimulants  with  a  little  chloral  (ten  grains)  at  night,  and  next 
day,  thinking  the  best  way  to  correct  her  false  sense  impressions  was  to 
subject  her  to  true  ones,  she  was  got  out  of  bed,  made  to  open  her  eyes, 
and  reasoned  with  as  to  the  absurdity  of  her  fancies,  and.  certainly  she 
seemed  to  be  reasoned  out  of  her  delusions  and  hallucinations  for  the 
time,  though  she  was  unsettled  in  conversation.  Her  room  was  kept 
cool  and  well  aired,  and  she  was  made  to  take  much  stimulants  and 
nourishment.  She  showed  a  tendency  to  fall  back  once  or  twice  into  her 
former  state,  especially  at  night,  but  to  a  much  less  extent,  and  got  quite 
well  in  a  few  days. 

I  lately  had  a  case  of  acute  delirious  mania  of  a  very  severe  type  fol- 
lowing an  attack  of  measles  in  a  young,  strong,  healthy  lady.  It  ran  a 
typical  course,  and  she  made  a  perfect  recovery  in  a  few  months. 

8.  Insanity  from  Deprivation  of  the  Senses. — I  saw  a  gentle- 
man, some  years  ago,  who  became  melancholic  and  suicidal  coincidently 
with  his  loss  of  sight  from  cataract,  and  who  improved  greatly  after  the 
operation  for  removing  it  was  partially  successful,  so  that  he  could  again 
see  even  in  a  dim  way  the  outer  world.  It  is  very  common  indeed  for 
those  who  are  deaf  to  become  quiet,  depressed,  and  irritable.  It  is  also 
common  for  such  persons  to  become  subject  to  hallucinations  of  hearing, 
and  so  insane  as  to  need  to  be  sent  to  asylums.    I  have  now  at  the  Royal 


INSANITY    OF    EXOPHTHALMIC    GOITRE.  419 

Asylum  four  or  five  such  cases.  It  seems  as  if  tliey  were  so  cut  off  from 
the  outer  world  by  their  deafness  that  their  subjective  experiences  became 
objective  realities  to  them.  In  the  case  of  all  men  the  senses  correct 
many  "delusions." 

9.  The  Insanity  of  Myxedema. — I  have  now  had  three  cases  of 
myxoedema  sent  to  my  care  as  patients  at  the  asylum  who  were  positively 
insane,  and  all  the  examples  of  the  disease  I  have  ever  seen  were  more 
or  less  affected  mentally,  if  they  were  not  technically  insane.  The  first 
case  I  had  sent  to  the  asylum  was  L.  0.,  a  woman  of  thirty-eight,  whose 
mother  was  said  to  be  "nervous,"  and  she  was  said  to  have  been  "drop- 
sical" for'  thirteen  years,  which  no  doubt  was  the  time  she  had  labored 
under  myxoedema.  She  had  become  lately  violent,  excited,  confused,  and 
full  of  changing  delusions,  with  hallucinations  of  hearing.  On  admission, 
she  was  incoherent  and  sleepless.  Under  discipline  and  nursing,  she 
became  more  quiet  and  slept  better,  but  was  still  confused  and  stupid. 
She  was  sent  home  after  about  five  weeks,  her  symptoms  having  become 
so  much  better  that  she  did  not  require  asylum  treatment,  the  mania  and 
delusions  having  disappeared,  though  confusion  and  mental  enfeeblement 
remained.  The  next  case  I  had  was  the  asylum  plumber,  L.  Q.,  get.  54, 
who,  having  labored  under  myxoedema  for  four  yeai's,  suddenly  one  day 
tried  to  poison  himself  in  a  deliberate  reasoning  way  on  account  of  a  bad 
wife.  In  consequence  of  this  and  of  his  mental  weakness  he  was  made 
a  patient  in  the  asylum,  but  he  soon  got  into  such  an  improved  condition 
that  he  was  discharged  from  the  books  as  a  patient,  and  remains  a  sort  of 
special  indoor  pensioner  of  ours,  an  illustration  of  myxoedema  for  the 
Cliniques  and  Medical  Societies  of  Edinburgh.  He  is  still  alive  now, 
after  twelve  years  from  the  beginning  of  his  disease,  contented,  torpid, 
enfeebled,  suspicious,  with  no  initiative,  no  temper,  and  no  affection  left 
for  anyone,  slow  in  his  mental  movements  as  he  is  in  his  muscles — in 
fact,  he  is  mildly  demented.  The  third  case  is  that  of  L.  P.,  set.  37  on 
her  admission  to  the  asylum  in  1878.  Three  years  before  admission  she 
became  depressed  with  hallucinations  of  smell — affirming  that  everything 
smelt  of  gunpowder.  After  three  years  of  depression,  she  became  exalted 
in  mind,  with  much  excitement.  Her  mental  condition  was  like  that  of 
a  typical  general  paralytic,  hilarious  and  facile,  contented,  impulsive, 
with  delusions  of  grandeur,  thinking  her  husband  had  lately  come  into  a 
fortune.  She  now,  after  five  years,  is  enfeebled  in  mind,  silly  in  speech 
and  conduct,  very  contented,  with  a  thick,  slow  articulation,  expression- 
less puffy  face,  with  no  affection  and  no  keen  desires. 

It  seems,  therefore,  judging  from  those  cases,  that  myxoedema  always 
tends  towards  a  mild  dementia  if  it  lasts  long  enough,  and  that  before 
that  occurs  some  patients  may  have  maniacal  and  melancholic  attacks. 

10.  Insanity  Associated  with  Exophthalmic  Goitre. — I  lately 
had  the  following  very  interesting  case,  which  will  be  more  fully  reported 
by  Dr.  Carlyle  Johnstone,  the  assistant  physician  in  charge  of  it : 

L.  S.,  admitted  into  the  Royal  Edinburgh  Asylum  on  the  26th  of 
November,  1881,  set.  32.  She  was  a  workingman's  wife,  of  active, 
steady  habits,  and  cheerful  disposition,  and  the  mother  of  three  children. 
For  the  last  three  years  she  had  been  gradually  losing  flesh  and  strength, 
and  had  latterly  been  treated  for  goitre.     A  few  days  before  her  admis- 


420  INSANITY    OF    EXOPHTHALMIC    GOITRE. 

sion  she  suddenly  began  to  express  delusions,  and  soon  became  intensely 
excited.  When  brought  to  the  asylum,  she  was  in  a  condition  of  acute 
excitement,  writhing,  struggling,  and  violently  resisting  all  attempts  at 
interference ;  talking  incessantly,  and  incoherently  using  profane  and 
obscene  expressions,  and  displaying  many  vague  and  fleeting  delusions. 
In  some  respects  her  excitement  was  hysterical  in  its  character.  She  Avas 
very  emaciated,  and  her  physical  condition  generally  was  very  weak. 
She  presented  the  ordinary  signs  of  exophthalmic  goitre — prominent 
eyeballs,  cardiac  disorder,  and  enlargement  of  the  thyroid  gland.  There 
was  slight  elevation  of  the  temperature,  with  a  rapid,  irregular,  and 
feeble  pulse. 

The  maniacal  condition  persisted,  with  frequent  remissions  and  exacer- 
bations, for  about  a  couple  of  months,  and  the  general  health  remained 
wretchedly  poor.  She  was  ordered  tonics  and  the  bromide  of  iron  con- 
tinuously. A  gradual  improvement  was  then  observed  in  the  mental 
symptoms,  and  the  relapses  became  less  frequent  and  less  serious.  Five 
months  after  her  admission,  she  was  able  to  employ  herself  usefully  in 
the  female  infirmary,  and  as  her  convalescence  appeared  to  become  estab- 
lished, she  settled  down  into  a  steady  house-worker,  and  behaved,  except 
for  occasional  hysterical  outbursts,  in  a  sober,  rational,  and  tolerably 
cheerful  manner.  With  the  abatement  of  the  excitement,  the  state  of 
nutrition  became  greatly  improved — the  increase  in  body  weight  being 
very  rapid.  There  was  little  alteration,  however,  in  the  signs  of  exoph- 
thalmic goitre,  and  during  her  residence  the  patient  only  menstruated 
once.  In  addition  to  these  adverse  symptoms,  nervous  phenomena  of  a 
very  grave  nature  began  to  make  their  appearance  between  three  and 
four  months  after  admission.  These  began  with  fainting  seizures,  followed 
by  a  feeling  of  numbness  in  the  left  arm,  which,  in  subsequent  attacks, 
extended  to  the  whole  left  side.  Gradually  the  power  of  the  left  limbs 
was  entirely  lost,  and  the  sense  of  touch  disappeared  from  the  whole  of 
the  left  side,  while  the  sense  of  pain  was  increased.  The  left  eyeball 
became  more  prominent  than  the  right,  violent  headache  set  in,  and 
patient  began  to  vomit  persistently.  She  died  on  the  19th  November, 
1882,  about  twelve  months  after  admission. 

The  autopsy  was  performed  thirty-six  hours  after  death.  The  calva- 
rium,  dura  mater,  and  pia  mater  were  considerably  injected.  There  was 
great  hypersemia  of  the  left  hemisphere,  but  in  consistence  and  other 
respects  that  portion  of  the  brain  was  tolerably  healthy.  The  right 
hemisphere  was  very  extensively  diseased.  Over  the  whole  of  the  supe- 
rior and  lateral  aspects  the  pia  mater  was  more  or  less  firmly  adherent, 
dragging  with  it,  on  removal,  in  several  places,  the  whole  depth  of  the 
cortical  matter.  The  white  matter  was  pink  and  mottled,  and  the  cor- 
tical matter  was  universally  soft  and  red,  and  in  many  places  quite  dis- 
organized. 

The  optic  nerves  and  tracts  presented  no  abnormality ;  the  cellulo- 
adipose  tissue  in  the  orbits  was  increased  in  quantity ;  the  thyroid  gland 
was  much  enlarged ;  there  was  a  large  thymus  gland ;  the  heart  was 
slightly  hypertrophied ;  the  other  organs  were  tolerably  healthy. 

This  case  suggests  several  questions.  If  the  extensive  disease  of  the 
gray  matter  of  the  convolutions  existed  all  the  time,  how  was  she  so  sane 


PSEUDO-INSANITY    OF    SOMNAMBULISM.  421 

mentally  for  a  portion  of  it?  Was  the  origin  of  the  case  a  vaso-motor 
one  ?  What  was  the  relationship  between  the  exophthalmus,  the  goitre, 
and  the  brain  disease? 

11.  The  Delirium  of  Young  Children. — Few  mothers  of  large 
families  but  have  had  experience  of  the  delirium  of  young  children. 
Some  children  are  much  more  subject  to  it  than  others.  Some  children, 
in  fact,  never  have  an  increase  of  temperature  over  99.5°  without  being 
delirious  at  night.  In  most  cases  it  is  a  pure  delirium  without  conscious- 
ness, attention,  or  memory,  but  in  some  instances  there  are  frightful 
hallucinations ;  in  others  an  excited  melancholia  of  short  duration,  with 
violent  screaming,  tearless  weeping,  and  all  the  usual  signs  of  mental 
depression.  I  have  seen  a  child  of  six  have  a  regular  attack  of  melan- 
cholia of  this  character  lasting  for  a  few  days.  The  bromides  and  cold 
to  the  head  with  hot  baths  are,  no  doubt,  the  best  treatment,  Avith  non- 
stimulating  nutrients  like  milk,  and  febrifuges  and  diaphoretics.  I  have 
known  a  child  of  eight  left  very  melancholic  after  an  attack  of  inflamma- 
tion of  the  lungs  had  passed  ofi",  and  after  the  temperature  had  fallen  to 
normal. 

12.  The  Insanity  of  Lead-poisoning. — This  is  a  variety  of  mental 
disease  which  Drs.  Rayner,  Savage,  A.  Robertson,  and  Atkins,  have  quite 
lately'  directed  attention  to.  Though  diseases  of  the  nervous  system 
from  lead-poisoning  have  been  long  known  to  medicine,  I  have  only  seen 
one  or  two  cases,  and  those  not  Avell  marked,  and  complicated  with 
alcoholism.  All  the  cases  have  motor  symptoms,  either  convulsions,  or 
paralysis,  or  muscular  tremblings.  The  mental  symptoms  are  most 
various,  from  coma  down  to  slight  lassitude;  but  hallucinations,  morbid 
elevation,  maniacal  attacks,  delusions  of  persecution,  have  been  the  chief 
symptoms  noticed  in  different  cases. 

13.  Post-connubial  Insanity. — I  lately  had  a  patient,  L.  R.,  who 
became  melancholic,  suicidal,  and  very  stupid  three  days  after  his 
marriage.  He  is  now  getting  well.  This  has  not  unfrequently  been 
observed.  The  mental  excitement  of  marriage,  culminating  in  an  excess 
of  sexual  excitation,  is  liable  to  upset  the  convolutional  stability  in  certain 
persons  predisposed  to  mental  disease.  In  my  experience  it  has  been  a 
curable  and  not  a  prolonged  form  of  mental  disease.  Some  brains  are  so 
liable  to  be  upset  in  their  mental  working,  that  it  is  no  wonder  the 
intensest  known  physical  excitement  produces  this  effect,  just  as  other 
brains  are  upset  in  their  motor  centres  in  like  circumstances  and  an 
epileptic  fit  occurs  on  each  occasion  of  intercourse. 

14.  The  Pseudo-insanity  of  Somnambulism. — One  cannot  admit 
that  the  actual  state  of  somnambulism  is  a  form  of  mental  disease  in  any 
true  or  scientific  sense,  for  the  patient  is  necessarily  asleep.  But  heredi- 
tarily it  is  often  very  closely  allied  to  mental  disease  and  to  epilepsy,  and 
I  have  ascertained  that  some  of  my  insane  patients  had  been  sleep- 
walkers during  the  period  of  adolescence.  Most  bad  and  confirmed 
sleep-walkers  have  a  neurotic  heredity,  or  a  nervous  temperament,  or  both, 
though  it  is  fortunately  quite  certain  that  few  of  them  ever  become 
insane.     Acts  of  violence,  homicide,  and  suicide  may  be  done  in  a  state  ot 

*  Journal  of  Mental  Science,  July,  1880. 


422  PSEUDO-INSANITY    OF    SOMNAMBULISM. 

somnambulism.  I  lately  saw  in  the  Edinburgh  prison  a  man  named 
Simon  Eraser,  whose  heredity  was  highly  neurotic,  who  had  been  an 
aggravated  sleep-walker  all  his  life,  who  during  his  somnambulism  had 
vivid  conceptions,  hallucinations,  and  illusions,  and  who  in  that  condi- 
tion did  all  sorts  of  purposive  acts  in  accordance  with  those  false  beliefs. 
He  remembered  his  somnambulistic  impressions  in  a  vague  way  after  he 
awoke.  He  was  most  difficult  to  awake.  He  once  went  up  to  his  neck 
in  the  sea  in  Norway,  and  did  not  awake.  At  last,  one  night  he  got  up, 
and  while  in  a  state  of  somnambulism,  imagining  he  saw  a  white  animal 
in  the  room,  he  seized  it  and  dashed  it  against  the  wall.  This  turned  out 
to  be  his  child,  whom  he  thus  killed  on  the  spot.^  He  was  passionately 
fond  of  the  child,  and  had  played  with  it  the  last  thing  before  it  had  gone 
to  sleep.  The  question  is — What  should  be  done  with  such  a  man 
to  protect  himself  and  others,  he  being  perfectly  sane  when  awake? 
Neither  the  lunacy  nor  the  criminal  laws  at  present  make  any  provision 
for  the  treatment  of  such  a  state  and  its  consequences. 

^  Dr.  Yellowlees  has  given  a  full  account  of  this  case  and  the  trial  in  the  Journal  of 
Mental  Science,  vol  xxiv.  p.  451. 


LECTURE    XIX. 

THE  MEDICO-LEGAL  AND   MEDICO-SOCIAL  DUTIES  OF   MEDICAL 
MEN  IN  KELATION  TO  MENTAL  DISEASES. 

The  medical  profession  has  grave  medico-legal  responsibilities  thrown 
on  it  by  the  provisions  of  many  of  the  forty  enactments  that  stand  on  the 
Statute  Book  relating  to  the  insane.  In  addition  to  those  statutes, 
judges,  juries,  and  administrators  of  the  law  constantly  call  in  medical 
men  to  help  them  in  the  solution  of  questions  that  they  only  can  solve. 
There  are  few  things  about  which  the  British  public  is  more  sensitive  than 
those  relating  to  the  liberty  of  the  subject,  to  civil  capacity,  and  to  the 
control  of  property.  In  addition  to  these  responsibilities,  there  are  most 
delicate  duties  of  a  purely  medical  and  medico-social  kind  thrown  on  our 
profession  by  the  exigencies  of  practice,  and  the  impossibility  of  finding 
elsewhere  so  qualified  and  wise  an  adviser  as  the  family  doctor.  There  is 
no  doubt  that  all  those  duties  should  be  done  with  much  care,  searching 
inquiry  into  facts,  and  a  grave  consideration  of  the  whole  eifects  of  any 
opinion  expressed,  or  of  any  act  done ;  and  a  special  knowledge  of  the 
subject,  experience,  sound  judgment,  and  caution,  are  all  qualities 
requisite  in  dealing  medico-legally  with  the  insane. 

The  chief  medico-legal  and  medico-social  duties  of  medical  men  in 
relation  to  mental  diseases  may  be  thus  classified : 

1.  Taking  the  responsibility  involved  in  treating  cases  at  home,  placing 
them  under  the  care  of  attendants,  advising  that  they  be  restricted  as  to 
liberty,  and  prevented  from  transacting  business.  This,  in  doubtful 
cases  and  in  the  early  stages,  of  the  disease,  is  often  a  very  serious  thing 
to  do.  The  patient  does  not  know  he  is  ill,  says  in  fact  he  is  quite  well, 
resents  as  an  insult  and  a  degradation  being  put  under  control,  and 
threatens  all  who  have  to  do  with  it  with  the  most  dire  consequences. 
The  doctor  often  loses  the  family  practice  after  a  case  of  insanity, 
whether  the  patient  recovers  or  not.  The  only  sound  and  safe  rule  for 
the  doctor  is  to  make  it  clear  that  he  only  advises  and  does  not  take  any 
legal  responsibility  whatever  for  the  steps  by  which  a  patient  is  controlled. 
Let  that  fiill  on  a  relation  who  has  the  legal  right  to  take  measures  for 
the  safety  of  the  patient,  and  on  no  account  be  assumed  by  the  doctor,  to 
whom  the  law  gives  no  such  authority  whatever  but  to  grant  certificates. 
If  the  patient  is  removed  to  lodgings  to  be  under  treatment,  the  relatives 
must  do  so.  It  need  not  be  the  nearest  relative.  It  is  often  desirable  to 
have  family  councils  under  those  circumstances.  Especially  Avhen 
husbands  or  wives  are  mentally  aifected,  some  of  the  blood  relations  of 
the  patient  should,  if  possible,  be  taken  into  consultation.  But  as 
regards  the  doctor  the  rule  is  clear.  Let  him  advise,  but  not  act.  I  have 
even  in  some  rare  cases  refused  to  take  the  responsibility  of  regular 


424  DUTIES    OF    MEDICAL    MEN    IN 

attendance  and  treatment,  without  first  getting  a  letter  of  protection  from 
legal  risk.  The  attendants  in  charge  are  the  servants  of  the  relatives, 
and  under  their  order  technically  and  legally,  however  much  in  fact  they 
may  be  under  the  doctor's  directions. 

In  England  a  patient  can  be  treated  at  his  own  home  or  anywhere  else, 
if  not  "  for  profit,"  without  certificates  of  lunacy,  as  long  as  his  friends 
desire,  and  so  long  as  he  is  not  badly  treated,  which  last  procedure 
subjects  those  responsible  for  it  to  very  heavy  punishment.  In  Scotland, 
a  patient  can  be  treated,  with  a  view  to  cure,  anywhere  out  of  an  asylum 
for  twelve  months  without  formal  certificates,  if  a  medical  opinion  to  that 
efiiect  and  intimation  is  sent  to  the  Commissioners  in  Lunacy.  I  do  not 
wish  to  discourage  the  early  treatment  with  a  view  to  cure  of  insane 
patients  in  private  houses.  I  only  point  out  the  conditions  on  which  only 
it  can  legally  be  done. 

2.  The  most  common  of  all  the  medico-legal  duties  thrown  on  medical 
men  is  that  of  signing  the  statutory  medical  certificates  for  placing 
patients  in  asylums,  or  under  care  in  private  houses.  This  is  done  for 
the  proper  treatment  of  the  patient,  and  often  for  his  safety  as  well  as  for 
the  safety  of  the  public.  The  form  of  certificate  is  fixed  by  statute,  and 
no  other  form  Avill  do.  The  form  is  practically  the  same  in  England, 
Scotland,  and  Ireland,  though  the  mode  of  placing  a  patient  in  the 
asylum  is  different  in  the  three  countries.  In  England  and  Ireland 
a  private  patient  can  be  placed  in  an  asylum  on  the  "order"  of  a  relation 
or  of  anyone  else  after  the  two  medical  certificates  have  been  obtained ; 
in  Scotland  the  sherifi"  must  sign  the  "order,"  after  having  seen  the  cer- 
tificates. Pauper  patients  are  placed  in  asylums  in  England  and  Ireland 
on  the  order  of  a  magistrate,  who  must  see  the  patient,  and  on  one 
medical  certificate,  while  in  Scotland  pauper  patients  are  placed  in  asylums 
in  the  same  way  as  private  patients,  that  is,  on  two  certificates  and 
a  sheriff's  order. 

As  to  the  grounds  on  which  a  British  subject  can  be  legally  deprived 
of  his  liberty  on  account  of  lunacy,  the  common  law  of  England  only 
recognized  as  a  sufiicient  cause  danger  to  the  patient  or  to  the  public, 
and  a  recent  decision  seems  to  imply  that  some  judges  still  hold  that  to 
be  the  law.  But  by  the  universal  practice  of  the  country,  sanctioned  by 
the  Commissioners  in  Lunacy,  the  recent  statutory  law  is  taken  as  super- 
seding or  supplementing  the  common  law;  and  that,  without  defining 
insanity,  or  prescribing  any  specific  grounds  on  which  a  patient  may  be 
detained  as  a  lunatic,  clearly  enacts  that  "care  and  treatment"  are  the 
chief  objects  of  his  detention,  and  his  being  dangerous  is  nowhere  made 
a  sine  qua  non.  This  being  so,  the  first  thing  a  medical  man  with  an 
insane  patient  who  needs  care  and  treatment  in  an  asylum,  or  to  be 
boarded  with  a  private  family,  has  to  do,  is  to  make  up  his  own  mind  in 
regard  to  the  definite  grounds  on  which  the  steps  are  to  be  taken.  Having 
done  so,  his  next  business  is  to  convince  the  patient's  responsible  relatives 
of  the  necessity  for  certification.  In  doing  this,  it  is  far  better  not  to 
press  them  too  strongly  at  first  if  they  do  not  see  the  necessity  for  it.  All 
that  is  necessary  is  to  explain  that  the  responsibility  rests  on  them,  not 
on  the  doctor.  It  may  in  some  rare  cases  be  necessary,  before  certifying, 
to  get  a  letter  from  a  responsible  person,  protecting  the  doctor  from  risk 


RELATION    TO    MENTAL    DISEASES.  425 

of  a  legal  action.  That  is  a  risk  no  medical  man  in  signing  a  certificate 
of  lunacy  should  subject  himself  to  if  he  can  help  it.  The  lunacy  statutes 
give  exemption  from  actions  if  the  facts  are  correct,  and  the  certificate 
bona  fide  and  correctly  filled  in ;  and  if  in  spite  of  this,  under  the  com- 
mon law,  actions  can  then  be  brought  against  medical  men  for  doing  a 
statutory  duty  in  a  legal  way,  they  must  just  protect  themselves  by  a 
letter  of  indemnification,  or  as  best  they  can.  In  the  case  of  pauper 
patients,  the  chief  responsibility  undoubtedly  rests  on  the  medical  man, 
to  whom  the  relieving  officers  or  inspectors  of  poor  must  refer  the  ques- 
tion of  asylum  treatment,  and  must  act  on  his  opinion. 

In  solving  the  question  of  whether  a  patient  should  be  certified  as  a 
lunatic  or  not,  the  first  thing,  of  course,  to  ask  one's  self  is,  "  Is  the  patient 
insane?"  And  it  is  well  to  be  prepared  to  say  what  kind  of  insanity  he 
labors  under.  To  detei*mine  this  question,  one  must  have  evidence  of 
mental  disease  observed  by  one's  self,  but  may  also  use  any  facts  proving 
it  as  ascertained  from  others  who  have  seen  the  patient.  If  he  is  insane, 
then  comes  the  further  question,  "Is  he  a  proper  person  to  be  detained 
under  care  and  treatment?"  Many  persons  are  insane  in  a  medical  and 
even  in  a  legal  sense,  yet  have  so  much  self-control  left,  or  their  mental 
peculiarities  are  so  slight  and  harmless,  that  they  are  not  proper  persons 
to  be  detained  under  care  and  treatment.  I  would  say  that  the  chief 
things  that  constitute  the  statutory  fitness  are  danger  to  themselves  or 
others  ;  disturbance  of  the  public  peace  ;  inability  to  care  for  and  manage 
themselves  and  their  affairs ;  acute  mental  symptoms  of  any  kind ;  or 
amenability  to  curative  treatment  which  cannot  be  applied  without  certi- 
fication. No  doubt  all  sorts  of  considerations  —  social,  monetary,  and 
domestic — come  in  before  determining  the  expediency  of  certification. 
One  has  to  ask  what  are  the  reasons  for  his  removal  from  home,  where 
he  would  naturally  be  in  sickness,  and  how  will  it  affect  him  and  his 
affairs  generally  ?  Then,  of  course,  it  is  proper,  having  determined  that 
he  should  be  certified,  to  ask  what  legal  risk  there  is  to  yourself  or  to  his 
relations.  I  know  an  undoubtedly  dangerous  lunatic  who  has  kept  him- 
self out  of  an  asylum  by  bribing  one  member  of  his  family  by  money 
gifts  to  oppose  his  seclusion  under  all  circumstances,  and  by  threatening 
anyone  of  his  children  who  moves  in  the  matter  with  disinheritance  in 
his  will.  It  may  be  necessary  to  see  the  patient  several  times  before  you 
can  make  up  your  mind.  When  those  questions  have  been  answered, 
and  you  proceed  to  certify,  (a)  fill  in  the  first  and  purely  formal  part  of 
the  certificate  in  all  cases  as  if  it  were  an  important  business  and  legal 
document,  looking  at  the  directions  on  the  margin.  Our  profession  is 
not  always  sufficiently  particular  about  this.  Lawyers  look  on  this  part 
as  of  much  importance.  Not  to  designate  the  patient,  and  put  in  his 
residence  at  the  proper  place,  is,  according  to  Sir  Cresswell  Cresswell's 
judgment,  to  invalidate  the  whole  document,  and  the  English  Commis- 
sioners always  return  it  to  the  Avriter  for  correction  if  this  is  not  done. 
The  reason,  no  doubt,  is  that,  there  being  ten  thousand  Thomas  Jones  in 
the  country,  it  is  necessary  to  discriminate  clearly  which  one  is  the  lunatic. 
In  England  and  Ireland  you  must  have  seen  the  patient  within  a  week 
of  certification,  in  Scotland  on  the  same  day. 


426  DUTIES    OF    MEDICAL    MEN    IN" 

(b)  Then  comes  the  most  important  part  of  all,  viz.,  the  "  facts  indi- 
cating insanity  observed  by  myself."  Without  these  facts  the  certificate 
is  not  valid  at  all.  By  all  means  put  in  first  the  most  evident  and  out- 
rageous insane  delusions  the  patient  labors  under  in  as  crisp  and  clear  a 
way  as  you  can.  No  evidence  of  insanity  is  so  satisfactory  to  lawyers  as 
insane  delusions.  Next  to  those  in  cogency  come  incoherence  of  speech, 
or  shouting,  or  outrageous  conduct,  or  loss  of  memory  and  reasoning 
power.  Put  into  the  certificate  some  of  the  patient's  very  words,  if 
possible.  Next  to  those  come  such  "facts"  as  relate  to  the  patient's 
appearance,  expression  of  face,  and  manner.  If  you  have  known  him 
before,  any  changes  from  his  normal  condition  should  be  noted.  By  the 
way,  in  putting  down  delusions  it  is  necessary  often  to  add  to  a  statement 
of  one,  the  Avords  "  which  is  a  delusion."  Some  things  may  be  quite 
true,  e.g.,  "He  says  he  has  X10,000  a  year,"  and  therefore  needs  this 
explanation.  On  the  other  hand,  such  delusions  as  "Says  he  is  God 
Almighty  "  do  not  need  anything  of  the  kind.  If  any  suicidal  or  homi- 
cidal expression  can  be  got  hold  of,  put  it  among  the  facts,  but  usually 
these  have  to  come  under  the  "facts  communicated  by  others."  Negative 
signs,  such  as  absolute  taciturnity,  insensibility  to  impressions  from  with- 
out, are  good  enough  "facts."  It  is  better  to  put  no  "facts"  that  do 
not  clearly  indicate  insanity,  if  possible,  but  there  are  some  cases  where 
the  evidence  must  consist  of  lesser  things  than  those  I  have  mentioned 
put  in  a  cumulative  way,  e.  g.,  "  His  manner  is  very  peculiar.  He  is 
slightly  incoherent  and  silly  in  speech.  His  memory  is  impaired  some- 
what. He  has  no  sane  interest  in  his  affairs  or  in  his  relations  or 
belongings.  His  eye  is  vacant  in  expression.  His  whole  conversation 
gives  me  the  impression  that  he  is  unfit  to  manage  his  affairs,"  were 
really  all  the  facts  observed  by  myself  that  I  could  put  down  as  the  results 
of  one  interview  with  a  person  of  mildly  enfeebled  mind.  It  is  quite  pro- 
per to  use  facts  observed  at  previous  interviews,  though  it  is  better  to  use 
those  at  the  last  interview  if  possible. 

I  could  give  instances  of  most  ridiculous  "facts"  put  into  lunacy 
certificates  by  medical  men.  "He  is  incoherent  in  his  appearance." 
"Eyes  restless  and  wandering,  but  following  the  usual  occupation  of 
breaking  stones."  "  She  says  she  is  in  the  family  way  (she  had  a  baby 
in  a  few  months)."  "  Reads  his  Bible,  and  is  anxious  about  the  salva- 
tion of  his  soul,"  are  examples. 

Never  put  in  such  statements  as  these — "  He  has  no  delusions."  "  His 
self-control  is  not  lost."  Those,  in  fact,  prove  sanity,  and  are  not  un- 
common. 

(a)  The  "facts  indicating  insanity  communicated  to  me  by  others" 
that  follow,  are  very  important  as  subsidiary  and  not  essential  points  of 
the  certificate.  Among  them  you  can  insert  descriptions  of  previous 
aggravations  of  conduct  and  speech,  of  attempts  or  threats  of  suicide,  or 
danger  to  others.     You  must  put  down  the  name  of  your  informant. 

(d)  The  signature,  residence,  and  dating  must  be  carefully  done. 
After  the  whole  certificate  is  completed,  I  advise  every  man  to  run  it 
over  carefully.  Few  men  are  so  accurate  that  they  will  not  sometimes 
omit  somethino". 


RELATION    TO    MENTAL    DISEASES.  427 

The  greatest  tact  is  necessary  often  to  bring  out  the  real  condition  of 
a  patient's  mind.  This  is  often  impossible,  in  fact,  even  when  you  know 
on  good  evidence  that  he  is  insane.  Especially  is  this  the  case  when  he 
thinks  you  are  a  doctor  come  to  certify  him.  He  then  naturally  conceals 
his  delusions,  and  puts  his  best  foot  foremost.  Sometimes  a  little  stratagem 
is  necessary.  The  weak  are  always  cunning,  and  it  seems  as  if  this  quality 
was  exaggerated  in  some  insane  patients.  By  all  means  get  the  cue  to  his 
delusions  if  they  exist,  and  as  full  a  knowledge  of  the  patient's  case  as  you 
can  before  you  see  him.  I  have  more  than  once  entirely  failed  to  educe 
facts  enough  on  which  to  found  a  certificate  in  the  case  of  a  man  I  knew 
to  be  insane  and  dangerous.  I  do  not  consider  it  a  justifiable  thing  to 
give  the  patient  drink  in  order  to  make  him  speak  what  is  in  his  mind, 
or  to  bring  out  his  peculiarities,  though  I  have  known  it  done  more  than 
once. 

3.  Medical  men  have  to  give  certificates  of  sanity  as  well  as  of  insanity 
sometimes.  These  need  great  care,  much  circumspection,  and  consider- 
able inquiry  into  the  facts  of  a  man's  life  and  behavior.  I  have  on  two 
occasions  had  insane  patients  leave  the  asylum  and  return  to  me  with 
certificates  of  sanity  got  from  incautious  doctors.  In  one  case  the  patient 
produced  and  kept  it  as  a  good  joke.  It  would  be  an  awkward  thing  for 
the  certifier  if,  after  getting  such  a  certificate,  the  patient  went  and  made 
a  will,  or  killed  himself.  In  a  way,  a  certificate  of  sanity  needs  more 
inquiry  before  it  is  given  than  a  certificate  of  insanity.  Certificates  of 
sanity  are  needed  to  set  aside  a  Curator  Bonis,  and  often  also  before  a 
man  is  allowed  to  resume  employments  and  public  appointments. 

4.  When  a  man  is  ipso  facto  deprived  of  his  civil  rights  and  the 
control  of  his  property  by  being  put  into  a  lunatic  asylum,  he  must  have 
his  property  looked  after  and  administered  for  his  benefit,  and  another 
legal  process  has  to  be  gone  through  for  that  purpose.  In  England  and 
Ireland  afiidavits  have  to  be  given,  stating  facts  indicating  insanity,  and 
especially  incapacity  to  manage  property,  which  are  sent  to  the  Court  of 
Chancery,  and  on  them,  as  prima  facie  proof,  an  inquisition  de  lunatico 
inquirendo  is  held  by  a  "Master  in  Lunacy,"  sent  to  the  patient's  resi- 
dence for  the  purpose,  at  which  the  medical  man  and  others  have  to  give 
viva  voce  sworn  evidence.  If  the  patient  is  found  lunatic,  one  person  is 
appointed  "  Committee  of  the  person,"  to  control  the  person,  and  another 
"Committee  of  the  estate,"  to  manage  the  property,  and  no  further 
certificates  are  needed  for  placing  him  in  an  asylum.  This  is  a  cumbrous 
and  expensive,  though  an  efficient  and  fair  process.  If  the  property  is 
under  XIOOO  in  value,  the  process  is  simpler  and  cheaper.  Some  such 
process  would  ahvays  be  necessary  for  doubtful  and  important  cases,  but 
in  ninety-nine  out  of  a  hundred  it  is  a  simple,  unnecessary  waste  of 
money  and  judicial  talent.  The  Scotch  process  is  far  simpler  and  less 
expensive.  Two  doctors  sign  certificates  "on  soul  and  conscience"  of 
the  man's  "  insanity,  incapacity  to  manage  his  own  affairs,  or  to  give  di- 
rections for  their  management,"  and  those  are  presented  with  a  petition 
from  a  near  relation,  stating  the  amount  of  his  property,  to  a  judge  of 
the  Court  of  Session,  who  orders  them  to  be  intimated  in  a  certain  place 
in  the  Court  for  eight  days,  after  which,  if  there  is  no  opposition,  a 


428  DUTIES    OF    MEDICAL    MEN    IN 

Curator  Bonis  is  appointed,  who  then  manages  the  lunatic's  property, 
and  acts  for  him,  after  finding  due  caution  for  the  proper  performance  of 
his  duties.  He  has  to  present  an  account  of  his  intromissions  to  the 
Court  every  year.  The  weak  point  of  the  Scotch  system  is,  that  usually 
no  proper  guardian  of  the  lunatic's  person  is  appointed.  The  nearest 
relative  commonly  acts  as  such.  Occasionally  a  Curator  Dative  is  ap- 
pointed to  control  the  person,  but  this,  with  the  process  of  "  Cognition," 
are  cumbrous,  antiquated  processes  seldom  resorted  to. 

5.  Medical  men  are  often  called  on  to  give  evidence  as  to  the  existence 
or  not  of  mental  disease  in  persons  accused  of  crime,  to  enable  the  law  to 
fix  or  to  absolve  from  responsibility.  In  Scotland  the  procurator-fiscal 
usually  has  a  medical  adviser,  with  a  view  to  determine  the  kind  of  pro- 
ceedings to  be  taken  in  cases  where  crime,  danger,  or  disturbance  may 
have  been  the  result  of  mental  disease. 

Crime  is  usually  committed  in  mania,  epileptic  insanity,  and  alcoholic 
insanity,  and  sometimes  in  puerperal  insanity,  delusional  and  homicidal 
melancholia,  sometimes  in  dementia  and  congenital  imbecility  in  an  im- 
pulsive way,  and  also  in  impulsive  insanity,  where  there  are  uncontroll- 
able homicidal,  kleptomaniacal,  pyromaniacal,  destructive,  or  animal 
impulses.  Some  of  the  complications  of  mental  disease  with  the  effects 
of  drunkenness  are  often  most  puzzling  both  to  medical  men  and  to 
lawyers.  My  experience  is,  that  crime  is  usually  committed  at  the  same 
stage  of  attacks  of  insanity  that  suicides  are  ordinarily  committed,  viz., 
in  the  incipient  stage. 

There  has  always  been  a  tendency  towards  a  divergence  of  view  between 
medical  men  and  lawyers  in  regard  to  the  amount  and  kind  of  mental 
disease  that  should  exempt  from  punishment  for  crime.  Certainly  the 
law  has  gradually  come  round  more  and  more  towards  the  medical  view — 
has,  in  fact,  recognized  the  facts  of  nature  in  mental  disease.  Judge 
Tracey  held  that,  except  a  criminal  was  irresponsible  as  a  wild  beast, 
he  should  sufter  punishment.  Lord  Mansfield  held  that  a  "knowledge 
of  right  and  wrong"  was  the  test.  The  twelve  judges  declared  in 
M'Naughton's  case  that  a  knowledge  of  right  and  wrong  in  relation  to 
the  act  committed  should  be  the  true  legal  test ;  Lord  Denman  said  that 
legal  responsibility  should  depend  on  the  presence  or  absence  of  insane 
delusion  ;  Lord  MoncriefF  has  laid  it  down  that  a  man's  habit  and  repute 
as  to  sanity  among  his  fellow-men  who  knew  him  well  should  determine 
his  legal  responsibility  for  any  crime  committed.  At  last  the  new 
criminal  code  of  Mr.  Justice  Stephen  proposes  to  make  the  man's  power 
of  controlling  his  actions  the  test,  and  with  that  view  every  medical  man 
will  agree.  He  says — "  The  proposition  which  I  have  to  maintain  and 
explain  is,  that  if  it  is  not,  it  ought  to  be  the  law  of  England,  that  no  act 
is  a  crime  if  the  person  who  does  it  is,  at  the  time  when  it  is  done,  pre- 
vented either  by  defective  mental  power  or  by  any  disease  affecting  his 
mind,  from  controlling  his  own  conduct,  unless  the  absence  of  the  power 
to  control  has  been  produced  by  his  own  default."  While  judges  during 
three  centuries  were  laying  down  these  rules  of  law,  men  that  we  now 
hold  to  be  insane  were  taking  away  their  own  lives  by  the  hundred  every 
year,  most  of  them  knowing  it  to  be  wrong  and  yet  doing  it — a  "crime," 


RELATION    TO    MENTAL    DISEASES.  429 

and  a  "motiveless"  one  in  most  cases.  Those  suicides  were  surely  thus 
exhibiting  to  all  Avho  had  eyes  to  see,  that,  in  this  respect  at  all  events, 
something  was  interfering  between  every  natural  instinct,  every  effort  of 
will,  and  every  motive  of  ordinary  human  action — that  something  being 
disease  and  disordered  function  of  the  brain. 

No  doubt  there  are  many  difficult  cases — cases  on  the  borderland  of 
disease,  cases  where  vice  and  mental  disease  are  mixed  up  puzzlingly, 
cases  of  mild  enfeeblement  of  mind,  cases  of  drink  voluntarily  taken 
when  its  effects  were  well  known,  and  after  being  taken  crime  Avas  com- 
mitted in  a  condition  of  delirium  or  short  frenzy.  We  must  admit  we 
have  no  definite  test  as  yet  for  detecting  minute  amounts  of  mental  dis- 
turbance. I  only  wish  we  medical  men  were  placed  in  a  more  satisfac- 
tory position  before  giving  evidence.  The  whole  facts  on  both  sides  are 
seldom  put  before  us,  and  we  are  regarded  and  treated  in  the  Avitness-box 
as  partisans — a  position  that  Ave  should  resent  as  derogatory  to  science. 
Certainly  Ave  should  never  become  partisans  willingly. 

6.  We  are  often  appealed  to  as  to  the  capacity  of  a  man  to  make  a 
will,  or  to  transact  ordinary  business,  or  to  contract  marriage.  The 
principles  on  Avhich  our  opinion  should  be  founded  for  the  tAvo  latter 
purposes  are  just  those  on  which  we  act  in  determining  the  question  of 
sending  a  patient  to  an  asylum.  In  regard  to  Avill-making,  great  atten- 
tion has  been  directed  to  the  subject,  and  there  are  certain  fixed  legal  and 
medical  principles  that  should  be  kept  in  mind  by  us.  The  great  trouble 
is  that  Ave  are  usually  not  consulted  at  the  time  of  making  the  Avill,  Avhen 
the  real  capacity  of  the  testator  could  be  examined  into,  but  are  placed 
in  the  Avitness-box  after  he  is  dead  with  one-sided,  imperfect  information, 
and  Avith  every  motive  operating  on  the  side  that  consults  us  to  prevent 
us  getting  at  all  the  facts.  In  will-making  we  must  enlarge  our  ideas  of 
the  disturbances  of  the  mental  functions  of  the  brain  beyond  those  com- 
prised under  technical  insanity.  The  senile  dotard,  the  man  exhausted 
in  strength  from  disease  and  approaching  death,  the  man  confused  in 
mind  from  fever  and  drink,  the  man  distracted  by  terrible  pain,  the  man 
whose  condition  is  Aveakened  so  that  he  is  made  mentally  unresisting  and 
facile  by  disease  and  by  the  near  approach  of  death,  may  all  require  their 
testamentary  capacity  to  be  tested.  It  is  most  important  that  a  skilled 
and  experienced  medical  man  should  be  asked  to  examine  into  the  testa- 
mentary capacity  of  such  cases  before  the  destination  of  great  sums  of 
money  is  irrevocably  decided  by  a  document  that  above  all  things  needs 
soundness  of  judgment  for  its  validity.  It  would  be  well  were  our  pro- 
fession more  called  on  for  this  purpose.  I  was  once  told  by  a  distin- 
guished counsel,  Avith  a  large  experience  in  the  Probate  Court,  that  he 
had  never  knoAvn  a  will  upset  where  a  respectable  doctor  had  witnessed 
it  after  examining  into  the  testator's  state  of  mind,  and  a  respectable 
agent  had  draAvn  it  up,  neither  of  them  taking  any  benefit  under  its  pro- 
visions. 

It  may  be  held  as  proved  by  legal  decisions  that  a  lesser  amount  of 
mental  capacity  is  needed  for  making  a  valid  will  than  for  managing 
property  or  enjoying  personal  liberty.  Patients  in  asylums  have  made 
good  Avills.     Patients  Avith  insane  delusions  that  did  not  affect  the  provi- 


430  DUTIES    OF    MEDICAL    MEN    IN 

sions  of  the  will  have  been  held  by  the  highest  tribunals  to  have  made 
good  wills  (Banks  vs.  Goodfellow).  Very  facile  persons  have  made  good 
wills,  and  those  on  the  point  of  death  constantly  make  wills  that  stand, 
while  wills  with  the  most  absurd  provisions  have  stood  in  law. 

When  a  medical  man  is  asked  to  examine  into  the  testamentary  capa- 
city of  a  patient,  he  should  insist  on  seeing  the  patient  alone,  or  at  all 
events  only  in  the  presence  of  a  nurse  or  a  family  agent,  and  the  first 
thing  to  be  ascei'tained  is  this,  (a)  "Is  the  patient  free  from  the  influence 
of  drink  or  dnigs,  and  in  his  usual  state?"  Then  (b)  "Does  he  know 
the  nature  of  the  act  he  is  to  perform,  and  the  effect  of  the  document  he 
is  to  sign?"  The  next  thing  (c)  is  to  find  out  if  he  is  not  influenced  in 
the  doing  of  it,  or  in  regard  to  any  of  its  provisions,  by  insane  delusion, 
or  by  an  insane,  morbidly  enfeebled  state  of  mind.  Then  (d)  ascertain  if 
there  is  facility  of  mind  from  bodily  weakness  or  any  other  cause,  or 
undue  influence  being  exercised  from  without.  Here  is  where  you  will 
find  the  benefit  of  being  alone  with  the  patient.  I  remember  an  old 
dying  man  confessing  to  me,  when  alone  with  him  in  these  circumstances, 
that  his  niece,  who  was  also  his  nurse  and  constant  companion,  was  really 
compelling  him  against  his  judgment  to  make  a  will  in  her  favor,  his  own 
volitional  and  resistive  power  being  weakened  by  his  state  of  bodily  weak- 
ness and  dependence.  The  influence  exerted  on  many  patients  in  bodily 
weakness,  especially  if  it  has  been  prolonged,  by  a  nurse  constantly  in 
attendance,  is  sometimes  absolutely  dominant,  and  quite  irresistible  by 
the  will  of  the  patient.  A  very  interesting  bit  of  medico-psychology 
this  is. 

Supposing  you  are  satisfied  so  far;  the  next  thing  (e)  is  to  make  the 
intending  testator  go  over  the  particulars  of  the  disposition  he  wishes  to 
be  made,  without  prompting,  or  suggestion,  or  leading  questions.  And 
he  should  be  made  to  do  this  twice,  with  certainly  a  quarter  of  an  hour's 
interval  between  the  two  statements.  You  can  then  see  if  the  disposition 
is  a  natural  one,  and  find  out  from  him  the  motives  for  the  will  being 
made,  and  for  any  provision  of  it  that  may  seem  strange.  In  fact,  are 
the  whole  motives  of  action  of  the  man  quoad  the  will,  sane,  reasonable, 
and  uninfluenced  by  morbid  motives?  Is  it  the  act  of  the  man  himself 
exercising  his  own  will  spontaneously?  I  remember  being  called  to  see 
a  man  who  was  dying  of  bronchitis  and  heart  disease,  with  his  breathing 
impeded,  his  strength  ebbing  away,  and  his  mental  power  impaired  by 
the  non-oxygenated  blood  supplied  to  his  brain.  He  had  made  a  will  in 
favor  of  a  former  mistress,  and  was  in  a  state  of  great  remorse,  and 
wanted  to  leave  his  money,  which  was  considerable,  to  his  relatives.  But 
he  could  not  twice  over  remember  all  the  provisions — these  being  a  little 
complicated.  I  refused  on  this  account  on  two  occasions  to  say  he  had 
testamentary  capacity.  But,  as  sometimes  happens,  he  became  more 
clear  in  mind  before  death,  and  I  was  hurriedly  sent  for  late  at  night  to 
see  him.  He  clearly  went  twice  over  the  provisions  he  wished  made  in 
his  will,  and  told  me  why  he  wished  these  made.  His  reasons  were 
natural  and  right.  The  lawyer  was  there  with  the  document  drawn  up, 
and  the  testator  had  just  power  to  make  his  mark  before  he  died.  Yet 
this  will  was  held  good  in  law  in  spite  of  an  attempt  to  upset  it.     The 


RELATION    TO    MENTAL    DISEASES.  431 

last  thing  (/)  you  have  to  ascertain  is  if  the  intending  testator  knows  in 
a  general  way  the  amount  of  the  property  he  has  to  bequeath.  I  lately, 
on  getting  to  that  point  in  the  case  of  a  very  sensible-looking  man,  was 
astonished  at  being  told  by  him  that  he  Avas  worth  £100,000,  which  I 
knew  to  be  quite  impossible,  and  of  course  no  will  was  made. 

It  is  most  necessary  not  to  let  a  good  motive  make  us  sanction  a  bad 
will,  however  natural  its  provisions  may  be,  however  much  trouble  or 
expense  it  may  save.  I  am  frequently  asked  to  sanction  wills  being 
made  by  persons  unfit  to  make  them,  on  account  of  the  convenience  of 
liaving  a  will  or  the  saving  of  expense  and  trouble.  I  have  found  but 
little  realization  of  the  impropriety  or  illegality  of  getting  dying  people, 
or  those  whose  minds  were  enfeebled  from  paralysis,  who  did  not  really 
know  what  they  were  doing,  to  sign  wills  as  a  matter  of  convenience, 
even  among  conscientious  reputable  people. 

7.  The  detection  of  feigned  insanity  is  a  duty  sometimes  laid  on  a 
medical  man.  There  are  no  fixed  rules  or  tests  by  which  feigned  in- 
sanity can  be  detected.  I  need  hardly  say  we  have  first  to  see  if  the 
type  presented  is  that  of  an  ordinary  kind  of  insanity.  Most  imitators 
mix  up  incoherent  maniacal  symptoms  with  silliness,  and  will  talk  no 
sense  at  all,  and  pretend  to  know  nothing.  In  fact,  they  overdo  their 
part.  The  patient  should  be  carefully  watched  all  the  time,  sometimes 
ostentatiously  watched  to  keep  him  at  it  for  a  long  time,  and  then  again 
when  he  does  not  know  he  is  observed.  No  sane  man  can  imitate  the 
dry  skin  and  lips,  furred  tongue,  constant  restlessness  by  day  and  night, 
high  temperature,  and  constant  sleeplessness  of  acute  delirious  mania, 
which  for  a  short  time  they  often  try  to  simulate.  A  man  imitating  the 
shouting,  etc.,  of  acute  mania  perspires  freely,  while  an  acutely  maniacal 
patient  seldom  does  so.  The  sensibility  to  pain  should  be  tested,  and 
sometimes,  in  prisons,  a  battery  is  found  useful  in  the  case  of  old  crafty 
malingerers.  I  have  heard  of  a  man  being  put  under  the  influence  of  a 
drug  before  the  doctor  was  known  to  be  coming,  in  order  to  produce  a 
real  stupidity  with  confusion  of  mind.  I  have  been  deceived  by  a  clever 
imitator  of  acute  mania  so  far  as  my  conclusions  were  arrived  at  from 
one  visit. 

I  have  known  a  really  insane  man  assume  an  exaggerated  insanity  to 
make  his  friends  think  the  asylum  was  doing  him  harm ;  and  a  sort  of 
grotesque  semi-volitional  imitation  of  mania  is  common  in  hypochondri- 
acal melancholies  to  convince  their  fi-iends  how  ill  they  are;  while  in 
hysterical  girls  imitations  of  maniacal  attacks  and  of  unconsciousness  are 
very  common  to  excite  sympathy  and  attract  attention. 

8.  One  of  the  most  difficult  and  often  most  responsible  duties  that  fall 
to  a  medical  man's  lot  is  to  give  confidential  family  advice  about  engage- 
ments to  marry  when  one  party  has  been  insane,  is  threatened  with 
insanity,  or  has  an  insane  heredity,  to  advise  as  to  the  education  and 
profession  of  children  of  a  very  neurotic  heredity,  and  to  advise  as  to 
the  significance  of  sudden  changes  of  conduct  and  sudden  outbreaks  of 
gross  immorality,  or  of  a  tendency  to  unnatural  crime,  or  other  motive- 
less and  unaccountable  conduct  in  previously  reputable  sane  people. 
Such  advice  may  have  the  most  serious  consequences,  blasting  lives  that 


432  DUTIES    OF    MEDICAL    MEN    IN 

might  have  been  happy.  My  feeling  is  always  against  the  marriage  of 
women  who  have  been  insane.  I  always  advise  young  men  or  young 
women  to  avoid  marrying  into  a  very  neurotic  and  insane  stock,  if  their 
aftections  have  not  gone  too  far.  The  risk  is  very  great.  I  agree  with 
the  French  medical  opinion  that  there  is  a  special  tendency  for  members 
of  neurotic  families  to  intermarry,  and  an  affective  affinity  among  such 
that  tends  towards  love  and  marriage.  That  is  no  doubt  bad  for  the  race, 
and  as  physiologists  we  should  try  and  stop  it  when  we  can.  To  have  a 
neurotic  young  man  marry  a  fat,  phlegmatic  young  woman  may  be  quite 
admissible,  and  a  good  safe  stock  may  result.  But  what  are  we  to  say 
about  the  marriage  of  the  neurotic,  thin,  hysterical  young  women,  with 
insanity  in  their  ancestry  ?  We  know  they  will  not  make  good  or  safe 
mothers.  Therefore,  in  them  we  ought  to  discourage  marriage.  How- 
ever good  its  physiological  efiect  might  be  on  the  individual,  bad  mental 
and  bodily  qualities,  as  well  as  tendencies  to  disease,  are  propagated  to 
future  generations.  They  leave  the  world  worse  than  they  found  it 
thereby,  the  disease  and  therefore  the  misery  in  it  being  increased.  The 
possible  compensation  of  a  genius  once  in  a  while  is  not  to  be  trusted  to. 
I  believe  a  healthier  kind  of  genius  would  result  from  better  stock. 
Science,  till  it  discovers  a  way  of  correcting  such  bad  stock,  must  say, 
do  not  propagate  it.  A  sporadic  case  of  insanity,  or  of  senile  break- 
down imitating  insanity,  may  occur  in  almost  any  family.  That  would 
not  warrant  any  such  advice  about  the  marriage  of  relations  as  I  have 
been  giving.  The  relatives  of  such  a  case  may  all  be  perfectly  sound. 
I  am  speaking  of  families  in  which  the  neurotic  temperament,  and  espe- 
cially those  in  which  the  nervous  diathesis,  is  present.  If  such  persons 
are  to  marry,  do  not  let  them  marry  young,  and  let  them  marry  into 
a  sound,  muscular,  fat,  non-nervous  stock.  Though  the  contrary  has 
been  the  rule,  my  advice  has  over  and  again  been  taken,  and  engage- 
ments to  marry  not  entered  into  on  the  ground  of  bad  heredity.  If  you 
are  asked  about  any  young  man  or  woman,  "Is  he  or  she  likely  to 
become  insane  or  not?"  say  that  science  does  not  yet  enable  us  to 
answer  that  question. 

As  to  the  mode  of  education  of  the  children  of  insane  or  neurotic 
parents,  there  can  be  no  doubt  whatever  that  it  ought  to  be  on  physio- 
logical lines,  and  under  medical  advice.  Such  children  should  all  be 
brought  up  in  the  country,  and  fed  mostly  on  milk  and  cereals,  and 
should  have  lots  of  fresh  air,  and  no  improper  excitement,  with  few 
children's  parties.  They  should  have  well-ventilated  class-rooms,  short 
school  hours,  and  their  lives  and  time  should  be  systematized.  Their 
weak  points  should  be  corrected  by  their  modes  and  conditions  of  life. 
They  should  be  kept  fat,  if  possible,  one  and  all.  They  should  have  no 
alcohol,  and  no  tobacco  till  after  twenty-four.  At  the  coming  on  of  the 
reproductive  period  of  life,  special  care  should  be  taken  with  them.  The 
sexual  appetite  is  most  difficult  to  manage  in  them,  and  by  them.  It  is 
often  strong,  disturbed,  and  apt  to  take  unnatural  forms,  while  the  power 
of  control  over  it  is  apt  to  be  small.  The  occupations  they  choose  should 
not  imply  intense  head  work,  or  a  sedentary  life,  or  excitement.  Make 
them  colonists,  sending  them  back  to  nature,  or  get  them  into  fixed 


EELATION    TO    MENTAL    DISEASES.  433 

salaried  places  with  systematic  work,  and  a  regular  holiday.  The  worst 
of  it  is  that  such  persons  often  tend  to  do  exactly  the  reverse  of  all 
this.  Some  especially  neurotic  children  need  very  special  modes  of 
education.  I  have  seen  cases  who  could  not  safely  be  sent  to  school. 
Through  precocious  stealing,  lying,  and  vice,  they  were  constantly  get- 
ting into  trouble.  They  were  without  much  moral  sense  or  self-control, 
and  had  erratic,  motiveless  ways.  I  have  seen  good  results  with  such 
children  sometimes  by  placing  them  in  a  quiet  family,  under  motherly 
care,  in  the  country,  under  special  rules  and  guidance,  and  away  from 
much  temptation.  Such  children  are  the  stock  out  of  which  the  insane, 
the  masturbators,  the  dipsomaniacs,  and  the  motiveless  criminals  arise, 
with  a  poet  or  a  genius  to  redeem  the  class  once  in  a  century,  and  to 
vindicate  nature's  law  of  compensation  in  the  world. 


28 


ABSTRACT 


STATUTES  OF  THE  UNITED  STATES,  AND  OF  THE  SEVERAL 

STATES  AND  TERRITORIES,  RELATING  TO 

THE  CUSTODY  OF  THE  INSANE. 


BY 

CHARLES   F.   FOLSOM,   M.D., 

FELLOW  OF  THE  AMERICAN  ACADEMY  OP  ARTS  AND  SCIENCES;    ASSISTANT   PROFESSOR  OF  MENTAL 

DISEASES,  HARVARD  MEDICAL  SCHOOL;    PHYSICIAN   TO  OUT-PATIENTS  WITH 

DISEASES  OF  THE  NEKTOCS  SYSTEM,  BOSTON  CITY  HOSPITAL. 


WITH  THE  ASSISTANCE  OP 


Mr.   HOLLIS    R.    BAILEY, 

ATTORNEY  AND  COUNSELLOR-AT-LAW. 


GENERAL  CONSIDERATIONS. 


The  insane  asylums  in  the  several  States  are,  as  a  rule,  under  the 
direction  of  a  board  called  trustees,  directors,  commissioners,  visitors, 
managers,  regents  or  administrators.  These  boards  are  in  some  cases 
elected  by  the  legislature,  more  commonly  appointed  by  the  governor  of  the 
State,  with  or  without  the  advice  or  consent  of  the  council,  or  senate,  or 
legislature.  The  boards  are  required  to  visit  the  hospitals  at  stated 
intervals,  and  to  make  annual  or  biennial  reports  to  the  governor  or  to 
the  legislature.  For  the  most  part  they  appoint  the  medical  officers  of 
the  asylums,  generally  Avith  the  approval  of  the  governor.  In  some 
States  the  governor  appoints  such  officers.  In  Maine  one  member  of  the 
board  must  be  a  woman,  and  in  Iowa  tAvo  may  be  women. 

In  West  Virginia  the  board  is  appointed  by  the  board  of  public  works. 
In  Florida,  Nevada,  Rhode  Island,  and  Wisconsin,  the  board  of  commis- 
sioners of  charitable  and  correctional  institutions  is  the  board  of  trustees. 
In  the  District  of  Columbia  the  visitors  are  appointed  by  the  President. 
In  North  Carolina,  Tennessee,  and  Virginia,  there  are  separate  asylums 
for  negroes.  County  asylums,  where  they  exist,  are  not  much  better 
than  almshouses  or  houses  of  correction  for  the  most  part :  and  the  laws 
requiring  them,  in  the  few  States  where  there  are  such,  are  often  disre- 
garded. In  Massachusetts  there  were  never  more  than  three,  and  there  is 
now  only  one. 

The  various  asylums  have  different  by-laws  regarding  payment  of  dues 
for  patients,  etc.  Women  are  employed  as  physicians  in  some,  and  in 
one  State,  Nebraska,  there  must  be  one  female  physician. 

In  those  States  where  the  laws  do  not  specify  regulations  for  the  com- 
mitment, or  admission,  of  private  patients,  the  trustees  are  allowed  to  in- 
clude that  matter  under  their  by-laws ;  and  they  generally  prescribe  a 
medical  certificate  from  one  physician,  or  tAvo,  which  in  some  States  must 
be  signed  under  oath. 

The  civil  laws  of  all  the  States  provide  the  right  of  habeas  corpus, 
according  to  law,  and  the  possibility  of  a  jury  trial  to  a  person  demand- 
ing his  discharge  from  an  insane  asylum  ;  they  deal  in  various  ways  with 
the  disqualifications  of  the  insane  as  to  holding  office,  voting,  serving  as 
jurors  or  witnesses,  managing  property,  marrying,  and  guardianship.  In 
a  few  States  incurable  insanity  is  ground  for  divorce. 


APPENDIX. 


ALABAMA. 


Patients  are  received  at  the  insane  asylum  from  the  several  counties 
of  the  State  in  proportion  to  the  numbers  of  their  insane  population.  In 
order  of  admission  the  indigent  insane  have  precedence  over  those  able 
to  pay,  and  recent  cases  over  those  of  long  standing. 

Paying  patients  are  received  on  the  following  requirements  :  (1)  security 
for  the  payment  of  charges  and  expenses  ;  (2)  a  certificate  of  insanity  from 
one  or  more  respectable  physicians ;  (3)  certain  prescribed  information  as 
to  the  condition  of  the  patient. 

Indigent  patients  are  admitted  only  after  application  to  the  judge  of 
the  probate  court  in  the  county  where  the  patient  resides.  The  judge 
being  informed  that  there  is  room  for  the  patient  at  the  asylum,  must 
call  one  respectable  physician  and  other  witnesses,  and,  either  "with  or 
without  the  verdict  of  a  jury,  at  his  discretion,  decides  the  questions  of 
insanity  and  indigence.  The  physician's  certificate  of  insanity  is  taken 
under  oath. 

If  a  paying  patient,  after  three  months,  becomes  indigent,  and  the 
superintendent  certifies  that  he  is  a  fit  patient  to  remain,  he  may  be  re- 
tained at  the  expense  of  the  State,  on  the  certificate  of  the  probate  judge 
of  his  county. 

Indigent  patients  after  two  years'  residence  in  the  hospital,  if  they  are 
not  likely  to  be  benefited  by  longer  treatment,  and  are  not  dangerous, 
may  be  removed  by  order  of  the  superintendent  to  the  poor-house  of  the 
county  of  which  they  are  resident. 

When  a  person  has  escaped  indictment,  or  has  been  acquitted  of  a 
criminal  charge,  on  the  ground  of  insanity,  the  court  shall  ascertain 
whether  the  insanity  in  any  degree  continues ;  in  which  case  the  court 
shall  order  the  prisoner  to  be  sent  to  the  insane  asylum. 

If  a  person,  held  in  confinement  to  await  trial  or  for  want  of  bail, 
appears  to  be  insane,  the  court  must  make  an  investigation,  call  a  respect- 
able physician  and  other  witnesses,  and,  if  necessary,  a  jury.  If  it  is 
proved  that  the  person  is  insane,  the  court  may  discharge  him  from  im- 
prisonment and  order  his  removal  to  the  hospital,  where  he  must  remain 

1  Code  of  Alabama,  1876,  U  1470-1503,  2753-2769,  2782,  2795-2799,  2802-2807, 
2894,  2895,  3756,  3758,  3836,  3838,  3843. 


440  APPENDIX ARIZONA. 

until  restored  to  his  right  mind.     In  case  of  a  recovery  he  is  remanded 
to  jail. 

Convicts  who  become  insane  while  serving  their  sentence,  or  who  are 
insane  at  the  expiration  of  their  term,  if  found  to  be  suitable  patients  for 
the  insane  asylum,  may  be  sent  there  by  the  Governor.  A  convict  sent 
to  the  insane  asylum  who  recovers  before  the  expiration  of  his  term  of 
imprisonment  must  be  returned  to  the  penitentiary  or  discharged,  as  the 
Governor  may  order. 


ARIZONA.'    (Territory.) 

Provisions  for  the  confinement  and  care  of  all  insane  persons  in  each 
county  shall  be  made  by  the  board  of  supervisors  of  each  county,  either 
in  the  county  jail  or  in  such  other  place  as  they  shall  think  best.  The 
Governor  may  make  contracts  for  the  keeping  and  treatment  of  the  insane 
in  any  hospitals  in  the  State  of  California. 

The  probate  judge  of  any  county,  upon  an  application  under  oath, 
stating  that  a  person  by  reason  of  insanity  is  dangerous,  shall  cause  the 
person  to  be  brought  before  him  for  examination,  shall  summon  two  or 
more  witnesses  acquainted  with  the  accused,  and  shall  cause  to  appear 
one  or  more  graduates  in  medicine  who  are  also  reputable  practitioners. 
The  physician  or  physicians  shall  be  present  during  the  hearing,  and  shall 
make  a  personal  examination  of  the  accused,  and  shall  set  forth  in  a 
written  statement  to  be  made  upon  oath :  (1)  his  or  their  opinion  as  to 
the  insanity  of  the  party  charged ;  (2)  whether  it  be  dangerous  to  the 
accused,  or  to  the  person  or  property  of  others,  that  the  accused  go  at 
large ;  (3)  whether  such  insanity  is,  in  his  or  their  opinion,  likely  to 
prove  permanent  or  only  temporary.  The  judge,  if  satisfied  that  the 
person  is  insane  and  unfit  to  be  at  liberty,  shall  make  an  order  directing 
his  confinement.  The  property  of  the  insane  person  is  applied,  so  far  as 
it  will  go,  to  paying  the  expense  of  his  commitment  and  maintenance. 

Upon  proof  that  a  person  confined  for  insanity  is  no  longer  insane  or 
dangerous,  the  probate  judge  may  direct  that  he  be  set  at  liberty. 

The  Governor  shall  appoint  some  suitable  person  to  visit  once  in  three 
months  the  asylums  in  California  where  there  are  patients  from  Arizona, 
to  see  that  they  are  properly  treated,  and  to  direct  the  discharge  of  those 
who  are  sufficiently  restored  to  reason. 

>  Compiled  Laws,  1877,  U  1193-1203. 


APPENDIX  —  ARKANSAS.  441 


ARKANSAS.^ 


Each  county  of  the  State  is  entitled  to  send  to  the  insane  asylum  a 
certain  number  of  patients,  proportionate  to  the  number  of  its  inhabitants, 
as  shown  by  the  last  census.  • 

Patients  are  committed  to  the  asylum  in  the  following  manner : 

(1)  Some  reputable  citizen  files  with  the  county  and  probate  judge  a 
written  statement,  certifying  that  the  patient  is  a  resident  of  the  county 
and  is,  to  the  best  of  his  belief,  insane,  and  ought  to  be  committed  to  the 
asylum  for  care  and  treatment.  This  statement  is  subscribed  and  sworn 
to  before  the  judge,  who  also  signs  it.  (2)  The  judge,  at  an  appointed 
time,  hears  the  testimony  of  the  witnesses  produced,  and  also  causes  an 
examination  to  be  made  by  one  or  more  regular  practising  physicians  of 
good  standing.  Interrogatories,  twenty-six  in  number,  touching  the 
habits,  history,  and  condition  of  the  patient  are  prescribed,  and  the 
physician  or  physicians  are  required  to  obtain  answers.  A  sworn  state- 
ment of  the  result  of  the  examination,  including  the  questions  and 
answers,  must  be  made  by  the  physician  or  physicians  and  presented  to 
the  judge.  (3)  If  the  judge  is  satisfied  that  the  person  is  insane  and  a 
fit  patient  for  the  asylum,  he  makes  his  decision  in  writing.  (4)  The 
superintendent  notifies  the  judge  whether  there  is  room  in  the  asylum 
unoccupied.  If  there  is  no  room,  the  name  of  the  insane  person  is 
entered  on  the  register  of  the  asylum,  and  the  patient  will  be  entitled  to 
admission  as  soon  as  there  is  a  vacancy.  (5)  If  the  judge  receives  word 
that  there  is  room  for  the  patient,  he  issues  an  order  to  the  sherilf  to  take 
the  insane  person  and  deliver  him  to  the  superintendent  of  the  asylum. 
Any  insane  person,  a  citizen  of  the  State,  whose  estate  will  not  maintain 
himself  and  his  natural  dependents,  may  be  admitted  to  the  asylum  and 
maintained  at  the  public  expense.  Insane  persons  having  property  may 
be  admitted  if  there  be  room. 

Patients  are  classified  into  three  classes:  acute,  chronic,  and  probably 
incurable.  If  the  hospital  is  crowded  with  patients,  a  preference  is  given, 
in  the  order  of  admission,  to  the  acute  class,  and  vacancies  may  be  made 
by  discharging  those  who  are  probably  incurable. 

A  patient  who  has  not  recovered  may  be  discharged  and  given  into  the 
care  of  his  guardian,  relatives,  friends,  or  removed  to  such  place  as 
is  provided  for  his  further  custody.  Such  removal  is  made  by  the 
sheriff,  or  his  deputy,  by  the  oi'der  of  the  county  and  probate  judge. 
Persons  who  have  not  recovered  may  also  be  removed  by  their  friends  with 
the  consent  of  the  superintendent,  or  by  the  direction  of  the  board 
of  trustees.  Patients  who  have  recovered  may  be  discharged  by  the  super- 
intendent, but  notice  shall  be  sent  to  the  county  and  probate  judge,  if 
the  removal  is  without  his  order. 

1  Arkansas  Digest,  1874,  ^§  302-326,  1227,  1228,  1828,  1966,  1988,  2001,  2002, 
3488-3539,  4496-^500,  4539. 

Acts  of  the  General  Assembly  of  the  State  of  Arkansas,  1883,  pp.  2,  18-26,  150- 
153,  182. 


442  APPENDIX — CALIFORNIA. 

The  sheriff,  of  each  county,  before  delivering  any  patient  to  the  super- 
intendent, shall  see  that  he  or  she  is  provided  with  suitable  clothing  to  the 
amount  prescribed. 

Any  pei'son  attempting  to  commit  a  patient  in  a  way  contrary  to  the 
provisions  of  the  statute,  is  guilty  of  a  misdemeanor,  and  liable  to  a  fine 
of  not  less  than  §50  nor  more  than  §300. 

If  a  lunatic  is  furiously  mad,  so  as  to  be  dangerous,  it  shallbe  the  duty 
of  his  guardian  or  the  person  in  charge  of  him,  to  confine  him  in  a  suitable 
place  until  the  next  term  of  the  circuit  court  for  the  county,  which  shall 
make  such  order  for  the  safe  keeping  of  the  person  as  the  circumstances 
of  the  case  may  require.  If  there  is  no  person  in  charge,  or  if  the 
person  in  charge  fails  to  take  care  of  such  lunatic,  any  judge  of  a 
court  of  record,  or  any  two  justices  of  the  peace  of  the  county,  may 
cause  such  insane  person  to  be  taken  into  custody  and  confined  until  the 
circuit  court  shall  make  further  order. 

Insane  persons  at  large  shall  be  arrested  by  any  peace  oflBcer  and  taken 
before  a  magistrate,  who  shall  make  such  orders  as  are  necessary  to  keep 
them  in  restraint  until  they  can  be  sent  by  due  process  of  law  to  the  asylum. 

Insane  paupers  may  be  taken  care  of  in  the  poor-house  of  the  county. 

If  in  a  criminal  case,  in  the  course  of  trial,  or  after  trial  and  before 
judgment,  the  court  shall  be  of  the  opinion  that  there  are  grounds  for 
believing  the  defendant  insane,  all  proceedings  shall  be  postponed  and  a 
jury  called  to  inquire  whether  defendant  is  of  unsound  mind.  If  found 
insane,  he  shall  be  kept  in  confinement  in  prison  or  in  the  county  jail, 
or  sent  to  the  lunatic  asylum  until  he  is  restored.  If  in  the  opinion  of 
the  court  he  is  sane,  the  trial  is  to  proceed  or  judgment  be  pronounced  as 
the  case  may  be. 

If  a  person  is  under  sentence  of  death,  and  the  sheriff  is  satisfied  that 
there  are  reasonable  grounds  for  believing  him  insane,  he  may  summon  a 
jury  to  tiy  the  question.  If  the  person  be  found  insane,  the  sheriff  shall 
suspend  the  execution  and  report  the  case  to  the  Governor. 

Persons  acquitted  of  crime  on  the  ground  of  insanity  must  be  so 
reported  by  the  jury  in  their  verdict,  and  they  shall  be  committed  to  the 
asylum  by  the  court  for  further  proceedings  or  for  discharge  upon  their 
recovery,  at  the  discretion  of  the  court.  Convicts  becoming  insane  are 
not  admitted  to  the  asylum  during  their  teiTQ  of  service,  but  are  treated 
in  the  penitentiary. 


CALIFORNIA.^ 


Patients  are  committed  to  the  Stockton  Asylum  in  the  following 
manner :  Whenever  it  is  made  to  appear  by  affidavit  to  a  magistrate  of 

1  Codes  and  Statutes  of  California,  by  Hittell,  1876,  Vol.  I.  |?  2136-2222;  Vol.  II. 
§§  11,763-11,766,  13,361,  14,367-14,373,  14,221-14,224,  14,582;  Vol.  III.  U  14,368, 
14,370,  14,373.     Statutes  of  California,  1881,  Chap.  ix. ;  1883,  Chaps,  liv.  and  Ixi. 


APPENDIX — CALIFORNIA.  443 

tlie  county  that  any  person  within  the  county  is  so  far  disordered  in  his 
mind  as  to  endanger  health,  person,  or  property,  he  issues  a  warrant  di- 
recting that  the  person  be  arrested  and  taken  before  some  judge  of  a  court 
of  record  in  the  county  for  examination.  This  judge  summons  two  or 
more  witnesses  from  the  persons  best  acquainted  with  the  insane  person, 
and  at  least  two  graduates  in  medicine.  The  physicians  must  be  present 
at  the  hearing  and  make  a  personal  examination  of  the  alleged  insane 
person.  The  physicians  must,  if  they  believe  the  person  dangerously 
insane,  make  a  certificate  stating  the  fact  and  showing,  as  far  as  possible, 
the  nature  and  duration  of  the  disease,  and  the  age,  residence,  and  con- 
dition of  the  patient.  The  judge,  if  he  is  satisfied  that  the  person  is  so 
far  insane  as  to  endanger  health,  person,  or  property,  makes  an  order 
that  he  be  confined  in  the  Asylum.  This  order  is  executed  by  the  sheriff. 
Idiots,  imbeciles,  and  persons  affected  Avith  delirium  tremens  are  not 
admitted. 

Commitment  to  the  Napa  State  Asylum  is  in  substantially  the  same 
manner,  except  that  the  application  is  made  to  the  County  Judge  or  to 
the  Probate  Judge  of  San  Francisco,  who  conducts  the  examination  and 
makes  the  order  for  commitment.  Also,  the  physicians  are  especially 
required  to  ascertain  whether  the  case  is  of  a  recent  or  curable  character, 
and  whether  the  insane  person  is  of  a  homicidal,  suicidal,  or  incendiary 
disposition,  so  as  to  be  dangerous  to  himself  or  the  community.  There 
is  the  same  provision  as  to  idiots,  imbeciles,  and  cases  of  chronic  or 
harmless  mental  unsoundness,  and  the  resident  physician  is  directed  to 
return  such  persons  to  the  county  from  which  they  Avere  committed. 

The  judge  shall  inquire  into  the  pecuniary  ability  of  persons  committed 
to  the  Asylum,  and,  if  there  is  property  sufficient  to  pay  charges,  the 
judge  shall  appoint  a  guardian  to  take  the  property  and  apply  it  to  paying 
for  the  maintenance  of  his  ward.  If  the  insane  person  is  indigent,  but 
has  husband  or  wife,  father,  mother,  or  children  living  within  the  State 
having  means,  they  shall  pay  for  his  support  to  the  extent  and  in  the 
manner  prescribed  for  paying  patients. 

If  the  kindred  or  friends  of  a  patient  make  it  appear  to  the  judge  of 
the  court  who  issued  the  commitment  that  they  are  capable  of  giving  him 
proper  care,  the  judge  may  issue  an  order  for  the  removal  of  such  person. 
No  other  order  or  application  for  release  shall  be  heeded  by  the  Trustees, 
except  it  be  the  order  of  a  court  or  judge  on  proceedings  in  habeas  corpus. 
If  it  is  brought  to  the  knowledge  of  the  judge  that  a  patient  so  removed 
is  not  properly  cared  for,  or  is  dangerous  for  want  of  care,  he  may  order 
such  patient  to  be  returned  to  the  Asylum. 

Non-residents  shall  not  be  supported  at  public  expense  in  either  asylum, 
except  temporarily  if  stricken  while  travelling  in  the  State. 

The  judges  authorized  to  commit  persons  may  send  all  patients  to  the 
Napa  Asylum  until  it  is  filled,  but  may  order  transfers  to  be  made  from 
one  asylum  to  the  other,  with  the  consent  of  the  resident  physicians  of 
each  asylum,  the  expense  of  the  transfer  to  be  paid  by  the  guardian  or 
friends  of  the  patient. 

If  doubts  arise  as  to  the  sanity  of  the  defendant  in  a  criminal  case, 
either  during  trial  or  before  judgment,  the  court  must  order  the  question 
to  be  submitted  to  a  jury,  and  must  suspend  the  trial  or  the  pronouncing 


444  APPENDIX — COLORADO. 

of  judgment.  If  the  defendant  is  found  insane,  the  court  must  order  him 
sent  to  the  State  Insane  Asyhim.  If  he  becomes  sane,  the  superintendent 
shall  send  word  to  the  sheriif  and  district  attorney,  who  must  put  the  de- 
fendant into  custody  until  he  is  brought  to  trial  or  judgment. 

If  a  person  has  been  sentenced  to  death  and  there  is  good  reason  to 
believe  that  he  has  become  insane,  the  sheriff,  with  the  concurrence  of 
the  judge  who  rendered  judgment,  may  summon  a  jury  to  inquire  into 
the  supposed  insanity.  The  district  attorney  is  to  be  notified,  and  is  to 
attend  the  inquisition.  If  the  defendant  is  found  insane,  the  sheriif  must 
inform  the  Governor,  who  may,  when  the  defendant  becomes  sane,  order 
execution  of  the  judgment. 

When  a  convict,  in  the  opinion  of  the  physician,  warden,  and  captain 
of  the  yard  of  the  State  Prison,  is  insane,  they  must  certify  the  fact  to 
the  Governor,  who  may  order  the  removal  of  the  prisoner  to  the  Insane 
Asylum.  If  the  convict  recovers  in  the  Asylum,  the  warden  of  the  State 
Prison  is  to  be  notified,  and  the  convict  is  returned  to  the  prison,  if  his 
term  of  imprisonment  has  not  expired. 


COLORADO. 


Until  the  asylum  for  the  insane  now  building  is  ready,  lunatic  paupers 
are  transported  to  some  convenient  asylum,  either  within  or  without  the 
State  limits ;  the  expense  to  be  paid  in  the  first  instance  by  the  county 
of  which  the  lunatic  is  a  resident.  This  expense  shall  be  repaid  the 
county  out  of  the  State  fund.  If  any  relatives  of  the  lunatic,  bound  by 
law  to  support  him,  and  having  means,  are  found  in  the  State,  the  money 
expended  is  to  be  collected  of  them. 

Whenever  any  reputable  person  shall  file  a  complaint,  duly  verified,  in 
the  county  court,  alleging  that  any  person  is  a  lunatic  or  insane  person, 
and  that  he  has  property,  and  is  incapable  of  properly  managing  the 
same,  the  judge  shall  order  a  jury  of  six  jurors  to  be  summoned  to  try 
the  question  of  sanity.  If  the  jury  find  that  such  person  is  so  insane  as 
to  be  unfit  to  manage  his  property,  the  court  shall  appoint  some  fit  per- 
son to  be  conservator  of  his  estate.  Whenever  any  reputable  person 
files  with  the  county  court  a  complaint  that  any  person  is  so  insane  or 
distracted  as  to  be  dangerous  to  himself  or  others,  if  allowed  to  go  at 
large,  the  judge  shall  issue  an  order  for  the  apprehension  of  such  person  ; 
provided,  also,  that  when  any  sheriff  or  constable  shall  find  any  such 
insane  person  at  large,  he  shall  apprehend  him  without  any  order  of  the 
court.  The  person  thus  arreted  shall  be  taken  forthwith  before  the 
county  court,  or  judge  thereof,  and  an  inquest,  by  six  jurors,  shall  be 

^  General  Laws,  State  of  Colorado,  1877,  pp.  602-610.     Session  Laws  of  Colorado, 
1879,  pp.  11,  87-92;  1881,  pp.  130,  141,  142;  1883,  pp.  32,  33. 


APPENDIX — CONNECTICUT.  445 

held  in  the  mode  above  stated.  It  may  be  held  without  delay,  if  the  alleged 
lunatic  so  elect;  otherwise  not  until  at  least  ten  days'  notice  has  been 
given  to  him,  and  to  a  guardian,  who  shall  be  appointed  for  him.  Until 
the  determination  of  the  inquest,  the  alleged  insane  person  shall  be  con- 
fined in  the  county  jail,  or  other  convenient  place.  If  the  jury  find  that 
such  person  is  so  insane  as  to  be  unfit  to  go  at  large,  the  court  shall 
commit  him  to  the  county  jail  or  other  convenient  place;  provided  that, 
both  before  and  after  such  inquest,  if  there  is  any  relative  or  friend  suit- 
able to  have  the  custody  of  such  alleged  insane  person,  the  county  court 
shall  order  him  to  be  delivered  into  the  custody  of  such  relative  or  friend. 
It  is  provided  further  that  both  the  above-mentioned  complaints  may  be 
filed  at  once,  and  one  inquest  held  to  determine  both.  No  inquest  shall 
be  had  as  to  the  lunacy  of  any  person  charged  with  a  criminal  offence 
until  ten  days'  notice  has  been  given  to  the  district  attorney  or  other 
prosecuting  ofiicer. 

In  case  any  lunatic  has  no  relative  or  friend  who  will  take  care  of  him, 
the  overseer  of  the  poor-house  of  the  county,  or  such  other  person  as  the 
county  commissioners  may  appoint,  shall  have  the  charge  of  the  body  of 
such  lunatic,  and  shall  comfortably  support  him,  at  the  expense  of  the 
county,  unless  there  is  property  in  the  hands  of  his  conservator.  If 
there  is  such  property,  the  conservator  shall  pay  the  expenses. 

If  any  person  shall  present  to  the  county  court  an  information  in 
writing,  stating  that  any  person  found  by  it  insane  has  been  restored  to 
reason,  the  court  shall  cause  the  fact  to  be  inquired  of  by  a  jury.  If, 
upon  such  inquest,  he  is  found  restored,  he  shall  be  set  at  liberty,  and 
his  conservator  shall  return  to  him  his  property. 

All  money  expended  by  any  county  for  the  support  or  custody  of 
lunatics  shall  be  reimbursed  to  it  out  of  the  State  fund. 


CONNECTICUT.^ 


When  a  pauper  in  any  town  is  insane,  a  selectman  of  such  town  applies 
to  the  judge  of  probate  of  the  district  where  the  pauper  resides,  asking 
for  his  admission  to  the  insane  hospital.  The  judge  shall  appoint  a  re- 
spectable physician  to  investigate  and  report  the  facts  of  the  case.  If 
the  physician  is  satisfied  of  the  insanity  of  the  pauper,  the  judge  shall 
order  the  selectman  to  take  him  forthwith  to  the  hospital.  A  part  of  the 
expense  of  his  support  is  paid  by  the  town,  and  the  balance  by  the  State. 

When  a  person  indigent,  but  not  a  pauper,  is  insane,  any  person,  on 
his  behalf,  may  apply  to  the  judge  of  probate,  who  shall  appoint  a 
respectable  physician  and  a  selectman  of  the  town  where  the  insane 

1  General  Statutes  of  Connecticut,  1875,  pp.  19,  20,  25,  56,  96-100,  536,  537. 
Public  Acts  of  Connecticut,  1875-1880,  pp.  25,  248,  249,  254,  327,  328,  342,  424, 
452;  1881,  pp.  10,  11;  1882,  pp.  193,  222;   1883,  p.  255. 


446  APPENDIX  —  CONNECTICUT. 

person  resides,  to  investigate  the  case  and  report.  If  the  judge  is  satisfied 
that  the  person  is  indigent  and  insane,  he  shall  order  him  to  be  taken  to 
the  hospital  by  the  person  making  the  application.  Half  the  expense  of 
his  support  shall  be  paid  by  the  town  and  half  by  the  person  making  the 
application. 

The  judge  shall  make  a  record  of  his  orders  for  admission,  and  shall 
send  copies  of  them  to  the  Governor. 

Paying  patients,  also,  may  be  committed  to  the  hospital  by  the  super- 
intendent, under  special  agreements,  and  comformably  to  law,  when  there 
are  vacancies.  Any  sum  paid  by  a  town  for  the  support  of  an  insane 
person  may  be  recovered  from  such  insane  person  or  out  of  his  estate,  if 
any  ever  comes  into  his  possession.  An  insane  person  may  be  put  in  any 
suitable  hospital,  retreat  for  the  insane,  asylum,  or  place  of  detention,  by 
the  relatives,  friends,  or  guardian,  on  the  presentation  of  a  sworn  certifi- 
cate, made  within  thirty  days,  signed  by  some  reputable  physician,  stating 
that  he  has  made  a  personal  examination  within  a  week  prior  to  the  date 
thereof,  and  that  such  person  is  insane.  This  certificate  and  the  char- 
acter of  the  signer  shall  be  certified  by  an  officer  authorized  to  administer 
oaths.  Any  person  thus  confined  may  be  removed  by  the  person  causing 
him  to  be  detained. 

On  a  written  complaint  to  any  judge  of  the  Superior  Court  that  a  person 
is  insane,  and  unfit  to  go  at  large,  the  judge  shall  appoint  a  committee, 
consisting  of  a  physician  and  two  other  persons,  one  of  whom  shall  be 
an  attorney-at-law,  judge,  or  justice  of  the  peace,  who  shall  examine  into 
the  case,  and  report  to  the  judge  the  facts  and  their  opinions  thereon. 
If,  in  their  opinion,  such  person  should  be  confined,  the  judge  shall  issue 
an  order  therefor. 

Any  dangerous  insane  person  at  large  may,  by  order  of  a  justice  of 
the  peace  and  the  first  selectman  of  the  town,  on  the  certificate  of  a 
respectable  physician  of  such  town,  be  confined  in  some  suitable  place. 
If  the  person  under  whose  care  he  shall  be,  or  who  is  bound  to  support 
him,  shall  not  so  confine  him,  he  shall  be  ordered  to  a  suitable  place  by 
the  justice  and  selectman. 

When  any  insane  person  is  at  large  in  any  town,  any  person  may 
complain  to  any  selectman  or  justice  of  the  peace  of  the  town,  and  if  he 
do  not  Avithin  three  days  provide  for  the  confinement  of  such  insane 
person  in  the  manner  above  stated,  the  complainant  may  complain  in 
writing,  under  oath,  to  any  justice  of  the  peace  in  the  town,  and  such 
justice  shall  thereupon  order  a  constable  to  bring  such  insane  person 
before  some  justice  of  the  peace  residing  in  the  town,  who,  if  finding  that 
such  insane  person  is  unfit  to  go  at  large,  may  order  him  to  be  confined  in 
some  suitable  place  for  such  time  as  he  deems  proper.  But  he  may  at 
any  time,  for  just  cause,  order  his  discharge.  And  the  Superior  Court, 
on  the  petition  of  any  person  so  confined,  or  of  his  relatives,  the  town  to 
which  he  belongs  being  made  a  party  respondent,  may  make  any  proper 
order  with  respect  to  his  future  disposal.  All  expenses  are  to  be  paid 
out  of  the  estate  of  the  insane  person,  if  he  has  any ;  if  not,  by  his 
relatives  liable  by  law  to  support  him ;  and  if  none  such,  by  the  town 
where  he  belongs. 

Persons  in  charge  of  any  place  of  detention  for  the  insane  may  dis- 


APPENDIX — CONNECTICUT.  447 

charge  persons  placed  therein,  other  than  criminals  and  such  as  have 
been  sentenced,  at  their  pleasure. 

The  Board  of  Charities,  consisting  of  three  men  and  two  women,  ap- 
pointed by  the  Governor  and  removable  at  his  pleasure,  shall  inspect  all 
institutions  in  which  persons  are  detained  by  compulsion,  to  ascertain 
whether  inmates  are  properly  treated,  and  whether  any  have  been  unjustly 
placed  or  are  improperly  held  therein.  The  insane  asylums  shall  be  visited 
as  often  as  once  a  month. 

Any  judge  of  the  Superior  Court,  on  information  to  him  that  any 
person  is  unjustly  deprived  of  his  liberty  by  being  detained  in  any  insane 
asylum,  or  in  any  place  for  the  confinement  of  the  insane,  or  in  any  in- 
ebriate hospital,  in  the  State,  may  appoint  a  commission  of  not  less  than 
two  persons,  who  shall  fix  a  time  for  a  hearing,  and  shall  have  one  or 
more  private  interviews  with  the  person  confined,  and  shall  make  due 
inquiries  of  the  physicians  or  other  persons  having  him  in  charge,  and 
shall  make  a  report  to  the  judge  of  the  facts  and  their  opinion  thereon. 
If,  in  their  opinion,  the  party  is  not  legally  detained,  or  is  cured,  or  his 
confinement  is  no  longer  beneficial  or  advisable,  the  judge  shall  order  his 
discharge.  But  no  commission  shall  be  appointed  as  to  one  person  oftener 
than  once  in  six  months. 

Any  superior  court,  city  court,  or  police  court,  before  which  a  person 
is  tried  on  a  criminal  charge,  and  acquitted  on  the  ground  of  insanity, 
may  order  such  person  to  be  confined  in  the  Connecticut  Hospital  for  the 
Insane  for  such  time  as  such  court  shall  direct,  unless  some  person  shall 
give  bond  to  the  State  to  confine  such  person  in  such  manner  as  the  court 
shall  order.  If  the  insane  person  has  any  property,  the  court  shall  ap- 
point an  overseer  with  the  powers  and  duties  of  a  conservator.  If  he  has 
no  estate,  the  expense  shall  be  paid  by  the  town  to  which  he  belongs ;  if 
he  belongs  to  no  town,  then  by  the  State.  Any  person  thus  confined,  or 
the  officers  of  the  Hospital,  may  petition  the  Superior  Court  of  the  county 
in  which  he  is  confined  for  his  enlargement.  The  selectmen  of  the  town 
to  which  he  belongs  shall  be  served  with  notice,  and  the  State's  attorney 
for  such  county  shall  appear,  and  the  court  shall  make  such  order  as  it 
shall  deem  proper  as  to  his  disposal. 

If  a  person  confined  in  jail  upon  the  commitment  of  a  justice  of  the 
peace  is  thought  to  be  insane,  or  an  idiot,  the  county  commissioners  shall 
appoint  a  reputable  physician  to  make  an  examination.  If  the  physician 
is  of  opinion  that  the  prisoner  is  insane,  or  an  idiot,  he  shall  make  a 
certificate  to  that  effect  and  deliver  it  to  the  commissioners.  The  com- 
missioners may  notify  the  selectmen  of  the  town  where  the  prisoner 
belongs,  and  they  shall  forthwith  remove  the  prisoner  from  the  jail,  and 
provide  for  him  in  some  suitable  place. 

Dipsomaniacs,  habitual  drunkards,  and  persons  addicted  to  the  use  of 
narcotics  or  stimulants,  so  far  as  to  have  lost  their  power  of  self-control, 
are  treated  as  lunatics  to  the  extent  that  the  probate  court  may  sentence 
them  to  an  inebriate  asylum  in  the  State,  for  not  less  than  four,  nor  more 
than  twelve  months,  except  that  dipsomaniacs  shall  be  committed  for 
three  years. 


448  APPENDIX — DAKOTA. 


DAKOTA.^    (Territory.) 

In  each  organized  county  there  shall  be  a  board  of  three  commissioners 
call  Commissioners  of  Insanity,  two  of  whom  shall  constitute  a  quorum. 
The  Judge  of  Probate  is  chairman  of  the  board.  The  other  two  members 
shall  be  appointed  by  the  County  Commissioners.  One  shall  be  a  re- 
spectable practising  physician,  and  the  other  a  respectable  practising 
attorney.  In  case  of  the  temporary  absence,  or  inability  to  act,  of  two 
of  the  commissioners,  the  Judge  of  Probate  may  call  in  a  respectable 
physician  or  lawyer  to  act  with  him. 

Application  for  admission  to  the  Hospital  must  be  made  to  the  Com- 
missioners in  writing,  sworn  to,  stating  that  the  person  on  whose  behalf 
the  application  is  made  is  believed  to  be  insane,  a  fit  subject  for  treatment 
in  the  hospital,  and  living  within  the  county.  His  legal  settlement  must 
also  be  given.  The  Commissioners  shall  at  once  investigate  the  case. 
They  may  require  the  alleged  insane  person  to  be  brought  before  them, 
or  not,  as  they  deem  best.  They  may  provide  for  the  suitable  custody 
of  the  person  pending  the  investigation,  and  their  warrant  for  the  purpose 
shall  be  executed  by  the  sheriff  or  any  constable.  They  shall  hear  testi- 
mony, and  any  citizen  or  relative  of  the  alleged  insane  person  may  appear 
and  oppose  the  application.  Some  regular  practising  physician,  who  may 
or  may  not  be  of  their  own  number,  shall  be  appointed  to  make  a  personal 
examination  and  report  whether  he  finds  the  person  insane  or  not.  The 
physician  shall  endeavor  to  obtain  from  the  relatives  of  the  person  and 
others  correct  answers  to  certain  prescribed  questions,  tAventy  in  number, 
relating  to  the  patient's  condition  and  the  nature  and  duration  of  the 
disease.  The  interrogatories  and  answers  are  to  be  attached  to  the  cer- 
tificate which  the  physician  is  required  to  make  and  give  to  the  Commis- 
sioners. 

If  the  Commissioners  find  the  person  insane  and  a  fit  subject  for  treat- 
ment in  the  hospital,  they  issue  a  warrant  authorizing  the  superintendent 
of  the  asylum  to  receive  and  keep  the  patient.  The  sheriff,  or  some  other 
person  appointed  for  the  purpose,  shall  execute  the  warrant  by  delivering 
the  patient,  with  a  duplicate  copy  of  the  warrant  and  the  physician's 
certificate,  to  the  superintendent.  If  there  is  any  relative  or  intimate 
friend  of  the  patient  who  is  a  suitable  person,  he  shall  have  the  privilege 
of  executing  the  warrant,  if  he  requests  it,  but  shall  have  no  fee  for  his 
services.  No  female  shall  be  taken  to  the  hospital  without  some  other 
female  or  some  relative  in  attendance. 

Patients  may  have  special  care  in  the  hospital,  if  the  same  is  agreed 
upon  and  paid  for  in  advance.  The  relatives  or  friends  shall  have 
the  privilege  of  paying  any  portion  or  all  of  the  expenses  of  a  patient. 

If  there  is  no  room  for  a  patient  in  the  hospital,  and  he  is  not  fit  to  go 
at  large,  the  Commissioners  shall  provide  for  his  care,  either  by  a  special 

»  Eevised  Codes  of  Dakota,.  1877,  p.  172.  Laws  of  Dakota,  1879,  pp.  68-86  ;  1881, 
pp.  98-102;  1883,  pp.  298-305. 


APPENDIX — DAKOTA.  449 

custodian  to  be  paid  for  by  the  friends  or  relatives  of  the  patient,  or,  if 
he  is  a  public  patient,  they  shall  require  him  to  be  cared  for  at  the 
expense  of  the  county  by  the  commissioners  of  the  county  or  overseers  of 
the  poor.  If  there  is  no  poor-house  or  more  suitable  place,  the  patient 
may  be  confined  in  the  county  jail,  or  he  may  be  sent  to  an  asylum  out 
of  the  Territory  to  be  designated  by  the  Governor.  The  commissioners, 
on  application  made  to  them,  may  also  make  provision  in  the  county  for 
the  care  of  persons  who  are  insane,  but  for  whom  admission  to  the  hospital 
is  not  sought.  The  commissioners,  if  any  insane  person  in  the  county 
is  suffering  from  Avant  of  proper  care,  on  information  of  the  same,  shall 
investigate  the  matter  and  make  needful  provision.  Persons  cared  for 
outside  the  hospital  may  be  transferred  there  by  authority  of  the  commis- 
sioners, when  a  vacancy  occurs,  and  without  further  inquest,  when  there 
has  been  an  inquest  within  six  months.  No  person  supposed  to  be 
insane  shall  be  restrained  of  his  liberty  except  in  the  way  already  stated, 
unless  it  be  temporarily  to  such  extent  as  may  be  necessary  for  the  safety 
of  persons  and  property,  until  proper  authority  can  be  obtained.  Any 
person  shall  be  guilty  of  misdemeanor  who  treats  an  insane  person  with 
wanton  cruelty. 

If  a  person,  confined  in  the  hospital,  is  alleged  to  be  not  insane,  the 
judge  of  probate,  either  of  the  county  where  the  hospital  is  situated,  or 
of  the  county  where  the  patient  has  his  settlement,  upon  an  application 
alleging  that  the  person  is  not  insane  and  is  unjustly  deprived  of  his 
liberty,  shall  appoint  a  commission  of  not  more  than  three  persons, 
of  whom  one  shall  be  a  physician,  and,  if  two  or  more  are  appointed, 
another  shall  be  an  attorney.  They  shall  make  examination  and  inquiry 
and  report  to  the  judge  of  probate.  Such  report  shall  be  accompanied 
by  a  statement  of  the  case  signed  by  the  superintendent.  If  the  judge 
on  this,  and  on  the  testimony  offered,  is  satisfied  the  person  is  not  insane 
he  shall  order  his  discharge.  No  commission  shall  be  appointed  in 
regard  to  the  same  party  oftener  than  once  in  six  months. 

If  a  patient  escapes  from  the  hospital,  the  superintendent  shall  notify 
the  commissioners  of  insanity  of  the  patient's  county,  who  shall,  if  he  be 
found,  have  him  discharged  or  returned  to  the  asylum,  unless  for  good 
reasons  they  have  him  cared  for  otherwise. 

Any  patient  who  is  cured  shall  at  once  be  discharged  by  the  superin- 
tendent. The  patient,  if  without  means,  shall  be  supplied  with  clothing 
and  a  sum  of  money  not  exceeding  $20,  to  be  charged  with  the  other 
expenses  of  the  patient.  A  patient  who  proves  incurable,  but  not  dan- 
gerous, may  be  removed  and  taken  care  of  by  his  relatives,  with  the 
consent  of  the  trustees  of  the  hospital.  The  friends  and  relatives  of  a 
patient  who  is  not  cured,  and  who  is  dangerous  to  be  at  large,  may  apply 
to  the  commissioners  of  insanity  of  the  county  where  the  patient  belongs, 
and  the  commissioners  may  have  the  patient  removed  from  the  hospital  and 
cared  for  within  the  county :  provided,  that  no  patient  under  a  charge  or  con- 
viction of  homicide  shall  be  discharged  without  the  order  of  the  trustees. 

When  patients  are  discharged  from  the  hospital  by  the  authorities 
thereof,  without  application  therefor,  notice  shall  be  sent  to  the  commis- 
sioners of  insanity  of  the  patient's  county,  and  they  shall  provide  for  the 
care  of  the  patient  unless  he  is  discharged  as  cured. 

29 


450  APPENDIX — DELAWARE. 

The  expenses  of  an  insane  person  may  be  collected  by  the  county  com- 
missioners from  his  estate  or  from  the  person  legally  bound  for  his  support. 

If  the  hospital  becomes  crowded,  discrimination  shall  be  made  in  the 
reception  of  patients  in  the  folloAving  order :  (1)  For  cases  of  less  than 
a  year's  duration.  (2)  For  cases  with  favorable  prospects  of  recovery. 
(3)  For  those  for  whom  application  has  been  longest  on  file.  (4)  Other 
things  being  equal,  for  the  indigent. 


DELAWARE.^ 

There  is  no  State  insane  asylum  in  Delaware.  Insane  persons  are 
cared  for  in,  the  county  almshouse,  or  in  some  asylum  in  Pennsylvania 
selected  by  the  Governor. 

Indigent  lunatics  or  insane  persons  are  removed  to  a  Pennsylvania 
hospital  in  the  following  manner :  Whenever  the  relatives  or  friends  of 
an  insane  person  apply  to  the  Chancellor  of  the  State,  and  present  a  cer- 
tificate of  two  practising  physicians  of  the  county  where  the  insane 
person  resides,  setting  forth  the  insanity,  the  cause,  if  known,  and  the 
necessity  of  better  medical  treatment  than  can  be  afforded  in  the  county 
almshouse,  the  Chancellor  shall,  if  satisfied  of  the  insanity  and  indigency, 
recommend  in  writing  to  the  Governor  that  such  indigent  insane  person 
be  removed  to  some  asylum  in  Pennsylvania.  But  each  county  shall  be 
entitled  to  have  only  five  patients  so  supported  at  any  one  time.  The 
expense  of  such  support  shall  be  paid  for  by  each  county. 

When  a  patient  thus  placed  is  cured,  or  is  so  far  recovered  as  to  be  fit 
for  removal,  or  for  one  year  has  shown  no  marked  improvement,  the 
principal  physician  of  the  hospital  shall  so  represent  in  writing  to  the 
Governor  of  Delaware.  Thereupon,  the  Governor  shall  make  a  written 
request  for  the  patient's  discharge. 

The  Governor  shall  request  a  detailed  report  annually  from  the  asylum 
respecting  the  condition  and  treatment  of  the  insane  from  Delaware,  and 
shall  transmit  it  to  the  legislature. 

If  any  patient  thus  placed  in  a  hospital  becomes  entitled  to  any 
property,  the  income  of  which  is  sufficient  for  his  support,  the  Chancellor 
shall  appoint  a  trustee  to  take  charge  of  the  same.  The  Chancellor  may, 
in  his  discretion,  require  that  such  insane  person  be  retained  in  the  asylum, 
paying  his  own  expenses. 

The  trustees  of  the  poor  of  the  several  counties,  on  the  recommendation 
of  the  Chancellor  and  of  the  resident  associate  judge,  shall  cause  any  of 
the  insane  poor  of  their  county,  whether  in  or  out  of  the  almshouse,  to  be 
removed  to  any  hospital  for  the  insane  in  the  United  States,  and  they 

1  Laws  of  Delaware,  Kevised  Code,  1874,  pp.  25,  «8,  233,  239,  240,  242-244,  650. 
Laws  of  Delaware,  1876,  pp.  103,  104 ;  1881,  p.  411. 


APPENDIX — FLORIDA.  451 

shall  make  contracts  for  their  admission  and  support.  The  expenses 
shall  be  paid  in  whole,  or  in  part,  by  the  said  trustees,  so  long  as  they 
judge  proper.  If  the  insane  person  has  any  property,  it  shall  be  applied 
to  defraying  the  expenses  of  his  support,  whether  in  the  almshouse  or 
elsewhere. 

The  overseer  of  the  almshouse  in  each  county  shall  receive  and  safely 
keep  all  insane  persons  committed  to  his  charge  by  order  of  the  levy  court. 

When  any  insane  person  is  confined  in  jail,  the  levy  court  may  issue 
an  order  that  he  be  placed  in  the  almshouse ;  and,  if  the  sentence  of  any 
convict  is  respited  on  the  ground  of  insanity,  the  convict  may  be  removed 
to  the  almshouse  under  such  order. 

If,  in  a  capital  trial,  the  defendant  is  acquitted  on  the  ground  of 
insanity,  the  court  may,  on  motion  of  the  Attorney-General,  order  that 
the  defendant  forthwith  be  committed  to  the  almshouse  of  the  county 
Avhere  the  case  is  tried,  or  of  the  county  where  the  insane  person  has  his 
residence,  or  the  court  may  order  that  such  person  be  placed  in  any 
lunatic  asylum  in  the  United  States.  The  court  may  appoint  a  trustee 
to  contract  for  his  commitment  and  support.  The  expenses  shall  be  paid 
by  the  county  where  the  oifence  was  committed,  or  where  the  insane 
person  has  his  residence ;  but,  if  such  insane  person  have  property,  it 
shall  be  applied  to  his  support.  Such  insane  person  may  be  set  at  large 
by  the  court  of  general  sessions  of  the  peace  and  jail  delivery  of  the 
county  where  the  case  was  tried  whenever  they  are  satisfied  that 
the  public  safety  will  not  be  thereby  endangered;  or  the  said  court  may 
order  his  removal  from  such  asylum  to  the  almshouse,  either  of  the  county 
where  the  act  was  committed,  or  of  the  county  where  he  resided. 

If  a  person  becomes  insane,  pending  a  civil  action,  the  court  may 
appoint  a  guardian  ad  litem,  or  the  action  may  be  continued  by  a  trustee. 


FLORIDA. 


It  is  the  duty  of  each  judge  of  the  circuit  court  of  the  State,  on  sug- 
gestion that  a  person  is  insane,  to  issue  a  writ  directing  the  sheriff  to 
bring  such  person  before  him  for  examination.  If  it  be  found  that  such 
person  is  a  lunatic  or  insane,  the  judge  shall  make  such  decree  as  is  usual 
or  necessary  in  such  cases.  If  it  appear  that  such  insane  person  is  desti- 
tute, the  judge  shall  order  him  transported  to  the  Asylum  for  the  Indigent 
Lunatics  of  the  State  of  Florida  for  care  and  custody ;  or  he  may,  in  his 
discretion,  direct  the  said  insane  person  to  be  delivered  for  custody  and 
maintenance  to  any  other  person,  who  shall  receive  not  more  than  $150 
per  year  for  such  maintenance. 

»  Digest  of  the  Laws  of  Florida,  1822-1881,  pp.  448,  747-750.  Acts  and  Resolu- 
tions of  Florida,  1883,  p.  64. 


452  APPENDIX — GEORGIA. 

The  Comptroller,  once  in  every  six  months,  shall  forward  to  the  State 
Attorney  of  each  circuit  a  list  of  the  lunatics  in  the  care  of  private  persons 
in  his  circuit.  The  State  Attorney  shall  cause  an  investigation  of  each 
case  by  the  grand  juries  of  the  several  counties,  causing  each  of  said 
lunatics  to  be  brought  before  them.  The  grand  jury  shall  make  a  report, 
a  copy  of  which  shall  be  sent  to  the  Attorney-General  and  to  the  Comp- 
troller. The  Attorney-General,  where  he  deems  it  proper,  shall  direct 
the  State  Attorney  to  institute  proceedings  before  the  judge  of  the  circuit 
court,  looking  to  the  change  of  the  custody  of  the  said  lunatic,  or  to  his 
final  discharge,  or  to  his  transfer  to  the  State  Asylum. 

The  physician  in  charge  of  the  State  Asylum  may,  when  directed  by 
the  Board  of  Commissioners  of  State  Institutions,  receive  into  said 
asylum  any  lunatic,  idiot,  or  insane  person,  whose  friends,  parents,  or 
guardians  are  able  and  willing  to  pay  for  his  care  and  support,  at  a  rate 
to  be  fixed  by  the  Commissioners. 

When  any  person  tried  for  an  offence  is  acquitted  by  reason  of  insanity, 
and  if  the  discharge  or  going  at  large  of  such  insane  person  shall  be 
considered  by  the  court  manifestly  dangerous,  the  court  shall  order  him 
committed  to  jail,  or  otherwise  to  be  cared  for  as  an  insane  person ;  or 
may  give  him  into  the  care  of  his  friends,  on  their  giving  security  for  his 
proper  care;  otherwise  he  shall  be  discharged. 


GEORGIA.^ 


The  State  Asylum  is  intended  for  the  care  of  lunatics,  idiots,  epileptics, 
or  demented  inebriates.  Inmates  are  divided  into  four  classes  :  1.  Pay 
or  pauper  patients,  residents  of  the  State.  2.  Pay  patients,  who  are 
non-residents.  3.  Insane  penitentiary  convicts.  4.  Insane  negroes,  in 
certain  cases.     Citizens  of  Georgia  have  a  preference  over  non-residents. 

Resident  pay  patients  are  admitted  upon  authentic  evidence  of  lunacy 
according  to  law,  or  by  a  certificate  of  three  respectable  practising  physi- 
cians well  acquainted  with  the  condition  of  the  patient,  or  a  certificate 
from  such  physicians  and  two  respectable  citizens.  Pay  patients  not 
resident  in  the  State  are  admitted  upon  authentic  evidence  of  insanity 
from  a  court  having  jurisdiction,  or  upon  a  certificate  from  their  own 
State  like  that  required  in  the  State  of  Georgia,  together  with  the  certifi- 
cate of  the  judge  having  jurisdiction,  that  the  certificates  of  the  physi- 
cians and  other  persons  are  genuine  and  entitled  to  full  credit. 

The  court  convicting  a  pauper  of  insanity  shall  certify  the  fact  that  he 
is  a  pauper.  If  he  has  any  means,  or  becomes  entitled  to  any  property, 
it  shall  be  applied,  so  far  as  it  will  go,  to  defraying  his  expenses.     If 

1  The  Code  of  the  State  of  Georgia,  1882,  ^  331(5),  1341-1374,  1658,  1852-1864, 
2735,  4299,  4666,  4673. 


APPENDIX  —  GEORGIA.  458 

there  is  any  one  liable  for  his  support,  the  amount  expended  may  be 
collected  of  him.    Otherwise  he  is  supported  at  the  expense  of  the  State. 

Upon  the  petition  of  any  person,  on  oath,  stating  that  another  is  liable, 
as  being  a  lunatic,  idiot,  or  person  non  compos  mentis,  to  have  a  guardian 
appointed,  or  is  a  fit  subject  to  be  committed  to  the  Lunatic  Asylum,  the 
Ordinary,  upon  proof  that  ten  days'  notice  has  been  given  to  the  nearest 
three  adult  relatives  of  such  person,  or  that  there  is  no  such  relative 
within  the  State,  shall  issue-  a  commission  directed  to  any  eighteen  dis- 
creet persons,  one  of  whom  shall  be  a  physician,  requiring  any  twelve  of 
them,  including  the  physician,  to  examine  the  person  and  hear  witnesses 
if  necessary,  and  make  a  return  to  the  Ordinary,  specifying  under  which, 
if  either,  of  said  classes  they  find  the  person  to  come.  If  they  find  him 
within  either  of  said  classes,  the  Ordinary  shall  appoint  a  guardian  for 
him,  or  commit  him  to  the  Lunatic  Asylum.  There  may  be  an  appeal 
from  this  finding  to  the  superior  court  of  the  county,  where  the  issue  shall 
be  submitted  to  a  special  jury. 

Guardians  of  insane  persons  are  authorized  to  confine  them  or  place 
them  in  the  asylum,  if  necessary  for  their  own  protection  or  the  safety 
of  others.  A  guardian  wilfully  failing  to  do  this,  is  liable  for  all  injuries 
inflicted  on  others  by  his  ward.  When  there  is  no  guardian  for  an  insane 
person,  or  the  guardian,  on  notice,  fails  to  confine  his  ward,  and  any 
person  makes  oath  that  such  insane  person  should  not  longer  be  left  at 
large,  the  Ordinary  shall  issue  a  warrant,  and  have  the  insane  person 
brought  before  him  on  a  day  specified.  Upon  an  investigation  of  the 
facts,  he  may  commit  such  insane  person  to  the  Lunatic  Asylum,  and,  if 
necessary,  cause  him  to  be  temporarily  committed  to  jail  until  he  can  be 
sent  to  the  asylum. 

If  a  patient  in  the  asylum  appears  to  be  incurable,  but  at  the  same 
time  harmless,  he  may  be  discharged  by  the  trustees  of  the  asylum,  or 
remanded  to  the  care  of  friends  and  relatives.  Pauper  patients  shall  not 
be  discharged  without  proper  clothing  and  a  sum  of  money  necessary  to 
carry  them  to  their  residence  or  to  the  county  from  which  they  were 
sent. 

If,  before  or  after  admission  of  a  pay  patient,  resident  or  non-resident, 
by  certificate,  the  alleged  lunatic  or  his  friend  or  relative  makes  a  demand 
of  the  superintendent  for  a  trial  of  the  question  of  lunacy  by  jury,  it 
shall  be  had  without  delay,  according  to  law,  in  the  county  where  the 
asylum  is  located.  The  like  demand  and  trial  may  be  had  by  all  patients 
who  have  been  convicted  of  lunacy,  if  the  person  demanding  it,  being  a 
relative  or  friend,  makes  affidavit  that  he  believes  the  alleged  cause  of 
commitment  did  not  and  does  not  exist,  and  that  the  conviction  was 
obtained  by  fraud,  collusion,  or  mistake.  The  same  right  exists  also 
when  there  is  an  affidavit  that  the  cause  of  commitment  has  ceased  to 
exist,  and  there  is  a  reftisal  by  the  superintendent  to  discharge. 

Provision  is  made  for  the  commitment,  admission,  and  care  of  in- 
ebriates, but  only  as  pay  patients. 

Insane  negroes,  residents  of  the  State,  are  to  be  committed  upon  the 
certificate  of  the  Ordinary  as  to  their  condition  mentally  and  pecuniarily. 

Whenever  there  is  an  application  for  commitment,  unattended  by  the 
requisite  evidence,  the  superintendent  may  receive  the  person  for  a  rea- 


454  APPENDIX — IDAHO. 

sonable  time,  provided  payment  is  made  in  advance  for  his  maintenance. 
If  a  person  who  has  been  once  properly  received  as  a  patient  has  been 
absent  so  long  as  three  months,  he  cannot  be  received  back  again  without 
going  through  the  regular  process  provided  by  law. 

If  a  penitentiary  convict  becomes  so  afflicted  as  to  be  a  fit  subject  for 
the  asylum,  he  shall  be  received  therein  upon  the  direction  of  the  Gov- 
ernor of  the  State,  or,  if  accompanied  with  the  certificate  of  the  physician 
of  the  penitentiary,  and  of  the  principal  keeper  thereof,  stating  the  fact. 
Such  convict  shall  pay  for  his  support,  if  he  has  means.  If  he  recovers 
before  his  term  of  service  has  expired,  he  shall  forthwith  be  sent  back  to 
the  penitentiary. 

When  a  person  has  been  acquitted  of  a  capital  crime  on  the  ground  of 
insanity,  and  is  committed  to  the  asylum,  he  shall  not  be  discharged 
except  by  special  act  of  the  legislature.  If  the  crime  is  not  capital,  he 
may  be  discharged  by  order  from  the  Governor.  If  sentence  was  sus- 
pended because  of  insanity,  the  superintendent  of  the  asylum  shall  inform 
the  presiding  judge  of  the  court  where  he  was  convicted  in  case  of 
recovery. 

If  a  convict  sentenced  to  death  becomes  insane,  the  sherifi"  shall  sum- 
mon a  jury  of  twelve  men  to  inquire  into  the  fact.  If  the  jury  find  him 
insane,  the  presiding  judge  of  the  district  shall  certify  the  fact,  and  the 
convict  shall  be  received  into  the  lunatic  asylum.  If  the  patient  recover, 
he  shall  be  removed  to  the  jail,  and  a  new  warrant  for  his  execution 
issued. 

When  the  plea  of  insanity  is  filed,  the  court  shall  cause  that  issue  to 
be  first  tried  by  a  special  jury,  and,  if  found  true,  the  defendant  shall  be 
committed  to  the  insane  asylum,  and  shall  remain  there  until  discharged 
by  the  general  assembly. 


IDAHO.^    (Territory.) 

There  is  no  provision  as  yet  for  an  asylum  for  the  insane  in  the  Terri- 
tory of  Idaho.  It  is  made  the  duty  of  the  board  of  county  commis- 
sioners in  each  county  to  take  care  of,  and  provide  for,  the  indigent  sick, 
idiotic,  and  insane  of  the  county  under  the  regulations  of  law. 

Whenever  it  shall  be  represented  to  the  probate  judge,  upon  petition, 
under  oath,  by  any  relative  or  friend  of  any  insane  person,  or  of  any 
person  who  is  mentally  incompetent  to  manage  his  property,  the  judge 
shall  cause  not  less  than  five  days'  notice  to  be  given  to  the  supposed 
insane  person  of  the  time  and  place  of  hearing  the  case,  and  shall  cause 
such  person,  if  able  to  attend,  to  be  produced  before  him  at  the  hearing. 
If,  on  examination,  it  appears  to  the  court  that  the  person  in  question  is 
incapable  of  taking  care  of  himself  and  his  property,  the  judge  shall 

1  Kevised  Laws  of  Idaho,  1874  and  1875,  pp.  310-318,  428,  430,  447-449,  526. 
Laws  of  Idaho,  1881,  U  170,  220,  529,  530,  898. 


APPENDIX  —  ILLINOIS.  455 

appoint  a  guardian  of  his  person  and  estate.  Every  guardian  so  appointed 
shall  have  the  care  and  custody  of  the  person  of  his  ward,  and  the  man- 
agement of  his  estate. 

If,  in  a  capital  case,  after  judgment  of  death  there  be  good  reason  to 
suppose  the  defendant  has  become  insane,  the  sheriflf,  with  the  concurrence 
of  the  judge  who  rendered  judgment,  may  summon  a  jury  of  twelve 
persons  to  inquire  into  the  question  of  the  supposed  insanity,  and  shall 
give  notice  to  the  district  attorney.  If  insanity  be  found,  the  sheriff'  shall 
suspend  the  execution  until  he  receives  a  warrant  from  the  Governor  or 
the  judge  of  the  court  by  which  judgment  was  rendered.  The  Governor 
may  appoint  a  day  for  the  execution  of  the  judgment  in  case  of  recovery. 

When  an  indictment  is  called  for  trial,  or  a  person  upon  conviction  is 
brought  up  for  judgment,  if  there  is  a  doubt  as  to  his  sanity,  the  court 
shall  order  the  question  to  be  submitted  to  the  regular  jury,  or  may  order 
a  jury  to  be  summoned,  in  the  way  above  described,  to  try  the  question. 
If  the  jury  find  that  he  is  insane,  the  trial  or  judgment,  as  the  case  may 
be,  shall  be  suspended  until  restoration  to  sanity;  and  the  court,  if  it 
deem  a  discharge  dangerous  to  the  public  peace  or  safety,  may  order  a 
commitment  to  the  custody  of  some  proper  person,  who  must  detain  the 
prisoner  until  he  becomes  sane.  Upon  his  recovery,  notice  must  be  given 
to  the  sheriff  and  district  attorney,  and  the  sheriff  shall,  without  delay, 
place  him  in  proper  custody  until  he  be  brought  to  trial  or  judgment,  or 
otherwise  legally  discharged.  The  expenses  of  his  care  and  custody  shall 
be  borne,  in  the  first  instance,  by  the  county  where  the  indictment  was 
found;  but  the  amount  may  be  recovered  back  from  the  estate  of  the 
defendant,  or  from  any  person  or  place  bound  to  maintain  him. 


ILLINOIS.^ 

Preference  is  given  to  recent  and  curable  cases,  and  also  to  patients  who 
are  violent  or  otherwise  troublesome,  when  the  asylums  are  crowded. 
The  Board  of  Commissioners  of  Public  Charities  shall  visit  the  insane 
hospital  and  other  places  where  the  insane  are  confined  and  exercise  a 
power  of  supervision.  They  may  examine  persons  under  oath,  and  they 
shall  report  annually  to  the  Governor. 

All  patients,  residents  of  the  State,  may  be  kept  free  of  charge  (each 
county  paying  for  the  support  of  its  insane  patients).  If  a  patient  is 
able  and  willing  to  pay  for  his  support,  he  may  do  so.  If  there  is  room 
in  the  hospitals,  residents  of  other  States  may  be  admitted  as  patients, 
upon  the  payment  of  the  cost  of  their  treatment. 

When  any  person  is  supposed  to  be  insane,  a  petition  is  sent  to  the 

1  Kevised  Statutes  of  Illinois,  Cothran's  Annotated  Edition,  1881,  pp.  197-210, 
363,  507,  508,  950-955,  1076.     Laws  of  Illinois,  1881,  pp.  151-153. 


456  APPENDIX — ILLINOIS. 

judge  of  the  county  court  by  a  near  relative  or  any  respectable  person  for 
proceedings  to  inquire  into  the  alleged  insanity.  On  the  filing  of  such 
petition,  the  judge  shall  have  the  alleged  insane  person  brought  before 
him  at  a  time  and  place  appointed  for  the  hearing  of  the  matter.  At  the 
time  fixed  for  the  trial,  a  jury  of  six  persons,  one  of  them  a  physician, 
shall  be  impanelled  to  try  the  case.  The  jury  shall  return  a  verdict 
showing  the  facts  of  the  case,  stating  whether  the  person  is  insane,  and, 
if  so,  whether  fit  to  be  sent  to  a  State  hospital.  If  the  person  is  found 
to  be  insane,  the  court  shall  enter  an  order  for  his  commitment  to  a  State 
hospital.  If  the  patient  is  not  a  pauper,  his  friends  have  a  choice  as  to 
the  hospital.  The  clerk  of  the  court  shall  apply  for  the  patient's 
admission,  and,  on  ascertaining  that  he  can  be  received,  shall  issue  a 
warrant  to  the  sherijBF  or  some  suitable  person  (preferring  a  relative,  when 
so  desired),  ordering  the  insane  person  to  be  conveyed  to  the  hospital. 
The  warrant  must  be  endorsed  by  the  superintendent  of  the  hospital, 
acknowledging  the  receipt  of  the  patient  and  returned  into  court.  The 
court,  if  it  is  necessary,  pending  the  trial  or  while  waiting  for  admission, 
may  make  such  order  as  the  case  may  require,  for  the  temporary  restraint 
of  the  supposed  insane  person,  by  a  sheriff,  jailer,  or  other  suitable 
person.  Idiots  and  persons  with  infectious  diseases  are  not  admitted 
to  the  hospitals. 

The  judge  of  the  county  court  is  to  see  that  pauper  patients  are 
removed  from  the  hospital  when  required  by  the  trustees.  Patients  not 
paupers  are  removed  by  their  friends,  who  must  give  bonds  to  do  so 
upon  admission.  If  a  patient  is  not  removed  as  required,  the  superin- 
tendent may  send  him  to  the  place  from  which  he  came. 

Whenever  application  is  made  from  a  patient  not  residing  in  the  State, 
if  the  superintendent  is  of  the  opinion  that  the  case  is  probably  curable 
and  there  is  room  at  the  time  in  the  hospital,  the  trustees  may  admit  the 
patient,  taking  a  bond  for  the  maintenance  of  the  patient,  and  for  his 
removal  when  required.  No  person. shall  be  detained  in  any  asylum  or 
hospital  for  the  insane  without  the  order  of  a  court  of  competent  juris- 
diction, or  the  verdict  of  a  jury. 

When  any  patient  shall  be  restored  to  reason,  he  shall  have  the  right 
to  leave  the  hospital  at  any  time,  and,  if  detained  contrary  to  his  wishes, 
he  shall  have  the  privilege  of  a  writ  of  habeas  corpus  on  his  own  appli- 
cation, or  on  that  of  some  one  in  his  behalf.  If  a  superintendent  or 
officer  of  an  asylum  improperly  receives  or  detains  a  patient,  he  is  liable 
to  fine  not  over  $500  or  to  imprisonment  for  one  year,  and  also  by  civil 
process  for  damages  for  false  imprisonment. 

If,  upon  the  trial  of  a  person  charged  with  crime,  it  appears  that  the 
crime  was  committed  by  the  person  while  insane,  and  the  jury  also  find 
that  the  person  has  not  entirely  and  permanently  recovered,  the  court 
shall  cause  the  person  to  be  taken  to  a  State  hospital  for  the  insane,  and 
there  kept  until  fully  recovered.  But  if  the  jury  find  that  the  person  has 
entirely  recovered  from  such  insanity,  he  shall  be  discharged  from  custody. 

A  person  who  becomes  insane  after  the  commission  of  a  crime  or  mis- 
demeanor, shall  not  be  tried  during  the  continuance  of  the  insanity ;  and 
if  after  trial  and  verdict  he  becomes  insane,  judgment  shall  be  arrested. 
If,  after  judgment  and  before  execution,  the  defendant  becomes  insane. 


APPENDIX  —  INDIANA.  457 

then,  in  case  the  punishment  be  capital,  the  execution  thereof  shall  be 
stayed  until  the  recovery  of  the  person  from  the  insanity.  In  all  these 
cases,  the  court  shall  impanel  a  jury  to  try  the  question  whether  the 
accused  be  at  the  time  insane. 

If  a  convict  in  the  penitentiary  becomes  insane,  he  shall  be  removed  to 
a  State  hospital  for  the  insane.  If  he  recovers  before  his  term  of 
imprisonment  has  expired,  he  shall  be  returned  to  the  penitentiary. 


INDIANA. 


Patients  are  entitled  to  treatment,  at  the  expense  of  the  State,  in  the 
State  asylums;  but  county  asylums  may  also  be  provided  by  the  county 
boards.  Before  commitment,  a  respectable  citizen  of  the  proper  county 
shall,  upon  oath,  make  a  statement,  in  writing,  before  a  justice  of  the 
peace  of  the  county,  answering  as  fully  as  possible  twenty-two  prescribed 
interrogatories  in  regard  to  the  alleged  insane  person's  condition  and 
history.  The  justice,  together  with  another  justice  of  the  peace,  and  a 
respectable  practising  physician  who  resides  in  the  county,  and  is  not  the 
medical  attendant  of  the  alleged  insane  person,  shall  immediately  visit 
and  examine  the  patient  in  relation  to  his  mental  condition.  The  justice 
of  the  peace  shall  then  order  the  clerk  of  the  circuit  court  of  the  county 
to  summon  the  regular  medical  attendant  of  the  patient,  if  there  be  one; 
also  the  person  making  the  statement,  and  the  persons  mentioned  by  him 
in  his  statement  as  witnesses;  also  the  selected  medical  examiner,  and 
any  other  persons  supposed  to  be  cognizant  of  facts  relating  to  the  case. 
A  hearing  shall  then  be  had,  the  two  justices  of  the  peace  presiding. 
The  medical  attendant  shall  make,  on  oath,  a  written  statement  of  the 
case.  The  medical  examiner  shall  also  make  a  statement,  in  writing, 
under  oath,  in  prescribed  form,  saying  that  he  has  heard  all  the  evidence, 
and  that,  in  his  opinion,  the  person  is,  or  is  not,  insane.  The  justices  of 
the  peace  shall  then  make  a  statement,  in  writing,  if,  in  their  judgment, 
the  person  is  insane,  and  a  fit  subject  for  treatment  in  an  asylum.  The 
papers  and  statements  are  all  filed  with  the  clerk  of  the  circuit  court  of 
the  county,  who  forthwith  applies  to  the  superintendent  of  the  Hospital 
for  the  Insane  for  the  admission  of  the  patient,  accompanying  the  appli- 
cation with  certified  copies  of  the  statements  and  certificates,  unless  the 
proper  friends  of  the  insane  person  prefer  to  place  him  in  a  private 
asylum  within  the  State,  when  a  written  permission,  under  the  seal  of 
the  court,  shall  be  given  them  to  do  so,  at  their  own  expense. 

The  superintendent  of  the  hospital,  on  receiving  the  application  of  the 
clerk,  shall  determine  from  the  same  whether  the  case  is  recent  and  pre- 

1  Revised  Statutes  of  Indiana,  1881,  |§  190, 1107, 1764, 1765,  2758-2782,  2835-2879, 
5142-5150,  6387.    Acts  of  Indiana,  Downey's  edition,  1883,  pp.  1651,  1652,  1749-1752. 


468  APPENDIX  —  INDIANA. 

sumably  curable,  or  chronic  and  less  curable,  or  idiotic  and  incurable.  If 
the  case  is  recent  and  curable,  the  superintendent  shall  grant  admission : 
if  the  case  be  chronic,  whether  curable  or  incurable,  admission  shall  be 
granted,  provided  there  be  room.  In  the  selection  of  chronic  cases,  each 
county  is  to  have  its  due  proportion,  according  to  its  population,  and 
priority  of  application  shall  also  be  considered.  Rejected  applications 
may  be  renewed  at  any  time  within  six  months  from  the  date  of  the 
inquest.  No  idiots  are  received  or  kept  in  the  hospital.  The  clerk  of 
the  circuit  court,  on  receiving  notice  that  the  patient  will  be  admitted, 
shall  have  him  taken  to  the  hospital  by  the  sheriff,  or,  if  so  desired,  by 
some  suitable  person  who  shall  be  a  friend  or  relative  of  the  insane  person. 
The  clerk  shall  see  that  there  is  a  proper  supply  of  clothing  for  the  patient, 
and,  if  the  same  is  not  otherwise  furnished,  it  shall  be  paid  for  by  the 
county,  as  also  the  funeral  charges,  if  the  patient  dies  at  the  hospital. 
Until  the  patient  can  be  admitted  into  the  hospital,  the  clerk  shall  have 
him  taken  care  of,  and,  if  necessary,  may  direct  his  confinement  in  the 
county  jail. 

Patients  restored  to  health  are  discharged  by  the  superintendent.  In- 
curable and  harmless  patients  shall  be  discharged  when  it  is  necessary  to 
make  room  for  recent  cases;  but  all  dangerous  persons  must  be  retained 
in  the  hospital.  The  clerk  of  the  circuit  court  of  the  county  from  which 
the  patient  was  sent,  on  notice  that  a  patient  not  restored  is  to  be  dis- 
charged, shall  issue  a  warrant  to  the  sheriff  to  remove  the  patient  to  the 
proper  township.  Patients  may  be  discharged,  uncured,  to  such  friends 
as  are  ready  and  able  to  take  them. 

A  patient  once  admitted  to  the  hospital,  or  to  any  asylum  in  the  State, 
and  discharged,  shall  not  be  again  admitted,  except  upon  the  affidavit  of 
a  respectable  practising  physician  of  the  county  where  the  patient  resides 
that  he  knows  the  patient;  that  he  has  been  adjudged  insane;  that  he  has 
been  in  a  hospital;  that  he  is  insane,  and  a  proper  subject  for  treatment. 
He  must  state  the  reasons  for  his  opinion.  The  clerk  of  the  court  shall 
also  make  a  certificate  that  the  adjudication  of  insanity  is  recorded  in  his 
office.  Certified  copies  of  these  certificates  will  serve  for  an  application 
for  admission  to  the  Hospital  for  the  Insane  or  to  a  private  asylum.  If 
a  person  has  been  adjudged  insane,  and  has  not  been  admitted  to  the 
hospital  within  six  months  from  the  date  of  the  inquest,  the  same  pro- 
ceedings as  in  the  case  of  a  recommitment  must  be  had.  A  transcript 
of  the  papers  filed  at  the  inquest  must  be  sent  to  the  superintendent, 
unless  previously  transmitted. 

Any  person  committed  as  insane  may  have  a  writ  of  habeas  corpus 
issued,  but  not  oftener  than  once  in  three  months. 

When  a  patient  is  discharged  as  cured,  the  superintendent  shall  furnish 
him  with  clothing  and  a  sum  of  money  not  exceeding  $20,  unless  other- 
wise supplied. 

When  complaint  on  oath  is  made  before  any  justice  of  the  peace  that 
any  person  is  insane  and  dangerous  to  the  community  if  allowed  to  re- 
main at  large,  such  justice  shall  issue  a  warrant  for  the  apprehension  of 
said  insane  person,  and  shall  summon  such  witnesses  as  may  be  demanded 
by  either  party.  The  justice  shall  summon  a  jury  of  six  reputable 
householders,   in  no  way  related  to,   or  personally  interested  in,   the 


APPENDIX  —  IOWA.  459 

alleged  insane  person  or  his  affairs,  who  shall  be  sworn  to  impartially  try 
the  issue.  If  the  jury,  after  hearing  the  evidence  and  examining  the 
alleged  insane  person,  who  is  to  be  personally  present  at  the  trial,  finds 
that  he  is  insane  and  dangerous  to  the  community  if  suffered  to  remain 
at  large,  the  justice  shall  appoint  some  resident  of  the  county  to  take 
charge  of  and  confine  him.  The  person  in  charge  shall  be  paid  by  the 
county,  and  may  be  changed  by  the  county  commissioners,  or,  if  the 
patient  is  ill-treated,  by  the  justice  of  the  peace.  The  proceedings  of  the 
jury  and  justice  of  the  peace  must  be  reported  to  the  circuit  court,  and 
at  the  next  term  thereof  the  issue  shall  be  tried  again  by  a  jury  of  twelve 
persons.  If  they  also  find  the  person  insane  and  dangerous,  the  court 
shall  confirm  the  appointment  of  the  person  in  charge  of  the  insane 
person,  or  appoint  some  one  in  his  place.  Such  insane  person  may  be 
sent  to  the  Hospital  for  the  Insane,  if  a  fit  subject  therefor.  The  cost 
of  adjudging  such  a  person  insane  and  of  caring  for  him  shall  be  paid 
out  of  his  property,  if  he  has  sufficient ;  otherwise  by  the  county.  The 
court  shall  appoint  a  guardian  to  care  for  such  property  as  is  subject  to 
the  payment  of  his  expenses.  If  the  jury  before  the  justice  of  the  peace 
find  in  favor  of  the  alleged  insane  person,  any  one  may  appeal  to  the 
circuit  court  on  giving  a  prescribed  bond. . 

When  a  person  tried  for  a  public  offence  is  acquitted  on  the  sole  ground 
that  he  Avas  insane  at  the  time  the  offence  was  committed,  the  fact  of  in- 
sanity shall  be  found  by  the  jury  or  by  the  court,  and  the  defendant  shall 
not  be  discharged,  but  shall  be  proceeded  against  upon  the  charge  of 
insanity,  in  the  manner  prescribed  for  the  commitment  to  the  hospital, 
except  that  no  preliminary  statement  in  writing  shall  be  required. 


IOWA.' 

There  shall  be  in  each  county  a  board  of  three  commissioners  of 
insanity,  including  the  clerk  of  the  circuit  court,  who  shall  be  clerk 
of  the  board.  The  other  two  shall  be  appointed  by  the  judge  of  the 
circuit  court,  and  shall  be,  one  of  them  a  respectable  practising  physician, 
and  the  other  a  respectable  practising  lawyer.  Temporary  vacancies  in 
the  board  may  be  filled  either  by  the  judge  of  the  circuit  court,  acting  as 
a  commissioner,  or  by  the  appointment  of  a  physician  or  lawyer.  The 
commissioners  have  cognizance  of  all  applications  for  commitment  to  the 
hospital,  or  for  the  safe  keeping  of  insane  persons,  except  in  cases  other- 
wise specially  provided  for.  Applications  for  commitment  to  the 
hospital  must  state  upon  affidavit  that  the  person  is  believed  by  the 
informant  to  be  insane  and  a  fit  subject  for  treatment  in  the  hospital,  and 
must  include  information  as  to  his  legal  settlement.     The  commissioners 

1  Revised  Code  of  Iowa,  Miller,  1880,  pp.  374-389;  p.  1038,  |  4472;  p.  1044,  ^g  4504, 
4505;  pp.  1061,  1062.     Acts  and  Resolutions,  State  of  Iowa,  1882,  pp.  58,  84. 


460  APPENDIX  —  IOWA. 

may  examine  the  informant  under  oath,  and,  if  they  find  there  is  cause 
therefor,  may  proceed  to  an  investigation.  They  may  have  the  alleged 
insane  person  brought  before  them,  if  advisable,  and  may  provide  for  his 
suitable  custody  pending  the  investigation.  They  shall  hear  such  testi- 
mony as  is  offered  for  and  against  the  application,  and  shall  appoint  some 
regular  practising  physician  of  the  county  to  make  a  personal  examina- 
tion of  the  patient  and  report  thereon.  He  may,  or  may  not,  be  of  their 
own  number.  He  shall  make  a  statement  certifying  whether  or  not  he 
finds  the  person  insane,  and,  as  a  part  of  his  statement,  shall  obtain,  so 
far  as  is  possible,  correct  answers  to  twenty  prescribed  interrogatories 
touching  the  condition  and  history  of  the  patient. 

The  commissioners  shall  make  a  finding  whether  or  not  the  person  is 
insane  and  a  fit  subject  for  the  hospital,  and  where  his  legal  settlement 
is,  if  ascertained.  If  the  case  is  a  proper  one,  they  shall  order  the 
person  to  be  committed  to  the  hospital,  unless  an  appeal  from  their 
decision  is  taken  to  the  circuit  court.  If  an  appeal  is  taken,  the  person 
shall  be  discharged  from  custody  pending  the  appeal,  unless  the  commis- 
sioners find  that  the  person  cannot  with  safety  be  allowed  to  go  at  large, 
in  which  case  they  shall  provide  for  his  care.  If,  upon  the  trial  in  the 
circuit  court,  the  person  is  found  to  be  insane,  the  court  shall  order  him 
to  be  committed  to  the  hospital.  If  there  is  no  appeal,  or  if,  on  appeal, 
the  patient  is  ordered  to  be  committed,  a  warrant  shall  issue,  in  the  one 
case  from  the  commissioners,  and  in  the  other  from  the  clerk  of  the 
court,  and  the  sheriff  or  some  person  appointed  shall  deliver  the  patient  to 
the  superintendent  of  the  hospital,  and  along  with  him  the  physician's 
certificate  and  the  finding  of  insanity.  If  any  relative  or  friend  who  is 
a  suitable  person  request  it,  he  shall  have  the  privilege  of  executing  the 
warrant.  If  the  patient  is  a  female,  there  must  be  some  other  female  or 
some  relative  in  attendance.  The  superintendent  shall  acknowledge  the 
receipt  of  the  patient  by  a  return  of  the  warrant,  which  shall  then  be 
filed  in  court. 

If  any  person  found  to  be  insane  and  a  fit  patient  for  the  hospital 
cannot  at  once  be  admitted  for  want  of  room,  or  for  other  cause,  the 
commissioners  shall  have  such  patient  suitably  provided  for  otherwise, 
either  as  a  private  or  a  public  patient.  Those  shall  be  treated  as  private 
patients  whose  friends  or  relatives  will  provide  for  them  without  public 
charge.  In  such  cases  the  commissioners  shall  appoint  some  suitable 
person  a  special  custodian  to  restrain  and  care  for  the  patient.  In  the 
case  of  public  patients,  care  shall  be  provided  by  the  board  of  supervisors 
at  the  expense  of  the  county.  If  there  is  no  poor-house  or  more  suitable 
place,  such  patients  may  be  confined  in  the  county  jail  in  charge  of  the 
sheriff.  The  commissioners  may  also  provide  for  the  care  and  restraint 
within  the  county  of  insane  persons,  either  public  or  private,  for  whom 
admission  to  the  hospital  is  not  sought.  On  information  that  any  insane 
person  is  suffering  for  want  of  proper  care,  the  commissioners  shall  make 
inquiry  and,  if  need  be,  provide  for  the  case.  Persons  who  have  been 
cared  for  outside  of  the  hospital  may,  at  any  time  within  six  months  after 
the  inquest,  be  transferred  to  the  hospital  simply  on  application,  unless 
the  commissioners  deem  further  inquest  advisable. 

On  the  application  of  the  relatives  or  friends  of  an  insane  person  in 


APPENDIX  —  IOV\^A.  461 

the  hospital,  who  is  not  cured,  the  commissioners  niay  authorize  his  dis- 
charge if  proper  provision  is  made  for  his  care,  but  no  one  under  a 
criminal  charge  or  conviction  shall  be  discharged  without  the  order  of  the 
district  court  and  notice  to  the  district  attorney.  If  an  insane  person 
cared  for  within  the  county  out  of  a  hospital  is  shown  to  be  no  longer  in 
need  of  care  or  restraint,  the  commissioners  shall  order  his  immediate 
discharge.  Any  patient  in  the  hospital  who  is  cured  shall  be  immediately 
discharged  by  the  superintendent,  who  shall  fiirnish  him  with  suitable 
clothing  and  money  not  exceeding  $20,  unless  he  is  otherwise  supplied. 
The  relatives  of  any  patient  who  is  found  incurable,  but  not  dangerous, 
may  take  charge  of  and  remove  him  with  the  consent  of  the  board  of 
trustees  of  the  hospital. 

The  trustees,  whenever  it  is  necessary  to  make  room,  may  order  the 
removal  of  incurable  and  harmless  patients,  and  the  commissioners  of  the 
counties  where  they  belong  shall  at  once  provide  for  their  care. 

If  for  want  of  room,  or  for  other  cause,  it  becomes  necessary  to  dis- 
criminate in  the  reception  of  patients,  a  selection  shall  be  made  in  the 
following  order :  (1)  Recent  cases  (of  less  than  one  year's  duration). 
(2)  Chronic  cases  (of  more  than  one  year's  duration),  presenting  the 
most  favorable  prospects  of  recovery.  (3)  Those  for  whom  application 
has  been  longest  on  file.     (4)  Other  things  being  equal,  the  indigent. 

If  a  patient  escapes,  the  superintendent  shall  cause  search  to  be  made, 
and  shall  notify  the  commissioners,  who,  if  the  patient  is  found,  shall  have 
him  returned. 

Each  county  shall  pay  the  expenses  of  its  own  patients,  and  the  State 
shall  pay  for  patients  who  have  no  settlement.  Patients  in  the  hospital 
may  receive  special  care,  if  their  friends  make  an  agreement  with  the 
superintendent  and  pay  for  the  same.  The  relatives  or  friends  of  any 
patient  in  the  hospital  shall  have  the  privilege  of  paying  any  portion  or 
all  of  the  expenses  of  such  patient.  If  an  insane  person  has  property, 
his  estate  is  liable  for  his  support,  but  the  board  of  supervisors,  if  they 
deem  it  a  hardship  to  take  such  estate,  may  forbear  to  do  so,  to  such 
extent  as  they  think  just  and  reasonable. 

There  shall  be  a  visiting  committee  of  three  persons,  of  whom  at  least 
one  must  be  a  woman,  who  shall  have  full  power  to  visit  the  hospitals, 
send  for  persons,  examine  witnesses  under  oath,  discharge  or  prosecute 
employes  for  cause,  and  correct  abuses.  Inmates  shall  be  allowed  to 
write  to  this  committee  once  a  week  and  to  receive  letters  from  them,  and 
the  same  shall  not  be  opened  by  the  superintendent  or  other  officers.  The 
committee  shall  annually  report  to  the  Governor. 

If  it  is  alleged  on  oath  that  a  patient  is  not  insane  and  is  unjustly 
deprived  of  his  liberty,  the  judge  of  the  district  or  circuit  court  of  the 
county  in  which  the  hospital  is  situated,  or  of  the  county  in  which  the 
patient  has  his  settlement,  shall  appoint  a  commission  of  not  more  than 
three  persons,  one  of  whom  shall  be  a  physician,  and,  if  two  are  appointed, 
one  a  lawyer.  They  shall  go  to  the  hospital,  see  the  patient  and  examine 
the  records  and  the  officers,  in  such  a  manner  as  they  deem  most  prudent. 
They  shall  then  report  to  the  judge  the  result  of  their  inquiries,  and 
shall  get  for  him  a  written  statement  of  the  case  made  by  the  superin- 
tendent.    If  the  judge  finds  the  person  not  insane,  he  shall  order  his 


462  APPENDIX — KANSAS. 

discharge.  This  commission  shall  not  be  repeated  oftener  than  once  in 
six  months  in  regard  to  the  same  party,  nor  appointed  within  six  months 
of  the  time  of  the  patient's  admission. 

If  a  person  charged  with  a  crime,  or  under  indictment,  is  found  by  the 
commissioners  to  have  become  insane,  and  to  be  still  insane,  they  shall 
have  him  sent  to  the  hospital  to  be  kept  by  the  superintendent.  When 
any  such  lunatic  is  restored,  he  shall  be  again  returned  to  jail  to  answer 
to  the  offence  alleged  against  him. 

If  a  defendant  be  acquitted  on  the  ground  of  insanity,  the  court  must, 
if  his  discharge  is  considered  dangerous  to  the  public,  order  him  to  be 
committed  to  the  insane  hospital,  or  retained  in  custody,  until  he  becomes 
sane. 

If  a  person,  after  conviction  of  a  crime,  becomes  insane,  the  Governor 
may  pardon  such  lunatic,  or  may  suspend  execution  of  his  sentence  and 
order  his  removal  to  the  hospital,  there  to  be  kept  until  restored  to  reason. 

If  a  reasonable  doubt  arises  as  to  the  sanity  of  a  defendant,  either 
before  trial  or  after  conviction,  the  court  must  have  a  jury  impanelled  to 
inquire  into  the  fact,  the  other  proceedings  in  the  case  meantime  to  be 
suspended.  If  the  jury  find  the  defendant  insane,  the  court,  if  it  deems 
his  discharge  dangerous,  may  order  his  commitment  to  the  insane  hospital. 
If  he  there  recovers,  he  shall  again  be  put  in  the  proper  custody  until 
brought  to  trial  or  judgment,  or  legally  discharged.  Any  person  who  in 
any  way  treats  an  insane  person  with  wanton  severity,  or  harshness,  or 
cruelty,  or  abuse,  shall  be  guilty  of  a  misdemeanor,  and  shall  be  liable  to 
an  action  for  damages. 


KANSAS. 


The  superintendent  of  one  of  the  two  asylums  in  the  State  is  desig- 
nated by  the  trustees  to  receive  all  applications  for  commitment,  and  is 
given  authority  to  determine  to  which  asylum  the  patient  shall  be  com- 
mitted. 

If  information  in  writing  is  given  to  the  probate  court  that  anyone  in 
its  county  is  a  lunatic,  or  a  person  of  unsound  mind,  or  an  habitual 
drunkard,  and  incapable  of  managing  his  affairs,  the  court,  if  satisfied 
that  there  is  good  reason,  shall  cause  the  facts  to  be  inquired  into  by  a 
jury.  It  is  the  duty  of  any  judge  of  the  probate  court,  justice  of  the 
peace,  sheriff,  coroner,  or  constable,  who  discovers  a  person  of  his  county 
to  be  of  unsound  mind,  to  make  application  to  the  probate  court,  as 
above  stated. 

At  the  time  fixed  for  trial,  a  jury  of  six  persons,  one  of  them  a  physi- 
cian in  regular  practice  and  good  standing,  shall  be  impanelled,  and  the 

'  Compiled  Laws  of  Kansas,  Dassler,  1879,  pp.61, 108-111,  529-537,  584,  762,763, 
883.     Laws  of  Kansas,  1881,  p.  78. 


APPENDIX  —  KANSAS.  468 

alleged  insane  person  may  be  represented  by  counsel.  The  jury  shall 
render  their  verdict  in  writing,  embodying  the  substantial  facts  in  a  form 
prescribed,  and  the  physician  upon  the  jury  shall  make  a  brief  medical 
statement  of  the  case,  so  far  as  ascertained,  and  of  any  other  circum- 
stances of  importance.  The  verdict  shall  be  recorded  at  large  by  the 
probate  judge.  If  it  appear  that  the  person  is  insane  and  fit  to  be  sent 
to  the  insane  asylum,  the  court  shall  make  an  order  for  his  commitment; 
if  "  of  unsound  mind,  or  an  habitual  drunkard,  and  incapable  of  managing 
his  affairs,"  it  shall  appoint  a  guardian  of  his  person  and  estate.  The 
court  may,  if  just  cause  appears  at  any  time  during  the  term  at  which 
the  inquisition  is  had,  set  the  verdict  aside,  and  cause  a  new  jury  to  be 
impanelled  to  try  the  case.  When  two  juries  concur  in  any  case,  the 
verdict  shall  not  be  set  aside.  If  it  shall  be  found  at  any  time  by  the 
court,  either  wuth  or  without  a  jury,  as  may  seem  proper  to  the  court, 
that  the  person  is  restored  to  his  right  mind,  he  shall  be  discharged  from 
care  and  custody. 

If  any  person,  by  lunacy  or  otherwise,  shall  be  furiously  mad,  so  as  to 
be  dangerous,  it  shall  be  the  duty  of  his  guardian,  or  other  person  under 
whose  care  he  may  be,  to  confine  him  in  some  suitable  place  until  pro- 
ceedings can  be  commenced  in  the  probate  court,  which  shall  make  such 
order  as  may  be  proper  for  the  support  and  safe  keeping  of  such  person. 
If  there  is  no  guardian  or  person  in  charge  to  care  for  him,  any  judge  of 
a  court  of  record,  or  any  two  justices  of  the  peace,  may  cause  him  to  be 
apprehended,  and  may  employ  some  one  to  confine  him  until  the  probate 
court  shall  make  some  order  in  regard  to  him. 

When  a  probate  judge  desires  to  commit  an  insane  person  to  the  State 
Insane  Asylum,  he  shall  send  a  statement,  in  a  prescribed  form,  to  the 
superintendent,  inquiring  whether  the  patient  can  be  admitted.  Upon 
receiving  a  reply  that  the  patient  will  be  received,  the  judge  shall  issue 
his  precept  to  the  guardian,  commanding  him  to  deliver  his  ward  into  the 
custody  of  the  superintendent,  and  at  the  same  time  give  to  the  steward 
of  the  asylum  a  warrant  directing  him  to  maintain  the  patient.  The 
warrant  states  also  who  is  to  bear  the  expenses,  whether  the  county  or 
the  guardian,  or  some  one  else.  To  determine  who  is  to  bear  the  ex- 
pense, the  probate  judge  shall  make  an  examination  of  the  property,  and, 
if  he  finds  that  the  insane  person  has  no  estate,  or  not  more  than  enough 
to  support  his  family,  shall  make  a  certificate  to  that  effect,  and  the  ex- 
pense of  his  support  shall  be  borne  by  the  county. 

Patients  supported  at  private  expense  may  be  placed  in  the  asylum 
upon  application  to  the  superintendent,  if  the  case  comes  within  the 
provisions  of  the  asylum  by-laws,  and  if  there  is  room  in  the  asylum. 
In  every  such  case,  the  superintendent  shall  be  presented  with  a  certifi- 
cate, signed  by  at  least  one  practising  physician  of  the  county,  stating 
that  he  has  examined  the  patient,  and  believes  him  to  be  insane.  There 
shall  also  be  presented  a  certificate  of  the  probate  judge  of  the  proper 
county,  stating  that  he  has  appointed  some  one  (naming  him)  as  guardian 
of  the  patient.  Questions  as  to  the  history  of  the  case  must  be  filled  out, 
and  forwarded  to  the  superintendent. 

The  person  or  court  placing  a  patient  in  the  asylum  may  remove  such 
patient  at  any  time,  and  the  superintendent,   under  direction  of  the 


464  APPENDIX  —  KENTUCKY. 

trustees,  may  discharge  any  patient  in  accordance  with  the  by-laws.  No 
idiot  or  person  with  a  contagious  disease  shall  be  committed  to  the 
asylum. 

Destitute  insane  persons,  who  have  been  refused  admission  to  the 
asylum  because  of  lack  of  room,  are  supported  at  the  expense  of  the 
State. 

When  a  patient  is  to  be  discharged,  the  probate  judge  of  the  proper 
county  shall  be  notified.  If  he  is  not  restored  to  sanity,  the  judge  shall 
issue  his  precept  to  the  guardian  of  such  person  to  remove  him  from  the 
asylum  to  the  proper  county.  If  he  is  recovered,  the  steward  may,  under 
direction  of  the  superintendent,  send  him,  at  the  expense  of  the  county 
or  person  charged  with  his  maintenance. 

If  a  convict  in  the  penitentiary  becomes  insane,  the  warden  shall 
notify  the  prison  physician,  who  shall,  if  he  deem  the  statement  true, 
summon  to  his  assistance  the  nearest  two  resident  physicians,  and  pro- 
ceed to  make  inquisition  of  the  facts  charged.  If  they  find  the  person 
insane,  they  shall  so  certify  to  the  warden,  who  shall  cause  the  insane 
person  to  be  removed  to  the  Asylum  for  the  Insane,  there  to  be  kept 
until  he  recovers,  or  is  discharged  by  expiration  of  his  sentence,  by 
pardon,  or  by  reprieve.  If  he  recovers  before  his  term  has  expired,  he 
shall  be  returned  to  the  warden. 

In  case  of  a  person  convicted  and  sentenced  to  death  becoming  insane, 
such  person  shall  not  be  executed  until  the  Governor  shall  be  satisfied, 
upon  the  oaths  of  twelve  good  and  true  men,  to  be  named  and  summoned 
by  the  warden,  upon  proper  inquiry  and  investigation  being  made,  that 
such  insanity  no  longer  exists. 


KENTUCKY. 


Each  of  the  three  asylums  receives  the  insane  of  its  own  district,  but 
patients  may  be  transferred  from  one  to  another,  in  case  any  one  is 
crowded.  Negroes  shall  be  sent  only  to  the  Eastern  and  Central  Asylums. 
It  is  the  duty  of  the  Governor  to  see  that  each  asylum  has  its  due  share 
of  patients. 

If  anyone  be  thought  of  unsound  mind,  it  shall  be  the  duty  of  some 
court  of  the  county  in  which  he  resides,  having  general  equity  jurisdiction, 
upon  the  application  of  the  attorney  for  the  commonwealth,  or,  if  he  be 
absent,  of  the  county  attorney,  to  cause  an  inquest  by  a  jury  to  be  held 
in  open  court  to  inquire  into  the  fact.  Inquests  may  be  held  by  a  judge 
or  chancellor,  by  the  presiding  judge  of  a  county,  the  judge  of  a  city 
court,  or  police  judge,  when  no  court  of  general  equity  jurisdiction  is  in 
session.     The  court  shall  appoint  some  member  of  the  bar  to  represent 

»  General  Statutes  of  Kentucky,  1881,  pp.  534-541,  642-652.     Acts  of  Kentucky, 
1881,  p.  15. 


APPENDIX  —  KENTUCKY.  466 

the  rights  of  the  person  alleged  to  be  of  unsound  mind.  It  shall  also  be 
the  duty  of  the  attorney  for  the  commonwealth,  or  for  the  county,  to 
prevent  any  persons  being  improperly  found  of  unsound  mind.  The  jury 
shall  take  a  formal  oath  to  find  truly  whether  the  person  is  of  unsound 
mind,  and,  if  so,  whether  he  is  an  idiot,  or  a  lunatic,  what  his  residence 
is,  and  what  property  he  or  his  parents  have.  If  the  judge  who  presides 
is  of  the  opinion  that  the  verdict  is  not  sustained  by  the  evidence,  or  is 
against  law,  he  shall  set  it  aside  and  award  a  new  inquest.  The  person 
alleged  to  be  of  unsound  mind  must  be  in  court  personally  before  the 
jury,  unless  it  shall  appear  by  the  oath  or  affidavit  of  two  physicians  that 
they  have  personally  examined  the  person,  and  that  they  verily  believe 
him  to  be  an  idiot  or  lunatic,  as  the  case  may  be,  and  that  his  condition 
is  such  that  it  would  be  unsafe  to  bring  him  into  court.  Every  fifth 
year,  in  the  case  of  idiots,  this  inquest  must  be  repeated  to  ascertain 
whether  any  change  has  taken  place  in  their  condition. 

All  lunatics  may  be  sent  by  order  of  the  court  to  the  lunatic  asylum. 
The  officer  who  presides  at  the  inquest  may  make  all  orders  for  the  security 
of  the  estate  and  care  pending  the  inquest  of  the  person  found  of  unsound 
mind.  The  papers  pertaining  to  the  inquest  shall  be  filed  with  the  clerk 
of  the  court  having  jurisdiction,  and,  at  the  next  term  thereof,  a  com- 
mittee shall  be  appointed  and  such  other  orders  made  and  taken  as  are 
necessary.  If  a  person  is  found  a  lunatic,  the  officer  who  presides  at  the 
inquest  shall  draw  up  a  brief  history  of  the  patient's  case  embracing 
certain  points  which  are  enumerated  in  the  Statutes. 

If  the  patient  is  delivered  at  the  hospital  within  six  months  after  the 
first  attack  of  his  lunacy,  and  the  fact  is  certified  to  by  the  circuit  judge 
of  the  district,  neither  the  county  nor  any  relative  shall  be  chargeable 
with  the  cost  of  his  detention  for  one  year  in  the  asylum,  nor  shall  a 
relative  in  such  case  be  chargeable  with  the  cost  of  his  transportation. 

Immediately  on  notice  that  a  person  has  been  ordered  into  confinement 
at  the  asylum  the  superintendent  shall  send  for  him  ;  but  where  the  safety 
of  the  lunatic  or  others  seems  to  require  it,  the  court  may  order  the  patient 
to  be  carried  to  the  asylum  immediately  without  waiting  for  his  being 
sent  for. 

Idiots  shall  not  be  sent  to  the  asylums,  unless  the  jury  find  that  they 
are  so  dangerous  that  they  cannot  be  safely  kept  by  a  committee  within 
the  county.  Pay  patients  from  other  States  may  be  admitted,  but  not 
when  their  reception  will  in  any  way  crowd  the  asylums  so  as  to  delay 
the  reception  of  patients  resident  in  Kentucky. 

No  private  patient  who  has  not  been  found  to  be  insane  by  regular 
inquest  shall  be  received  into  either  asylum.  Nor  shall  any  patient  be 
discharged  as  cured,  or  delivered  into  the  custody  of  friends,  if  his  friends 
have  placed  him  in  the  asylum,  except  by  permit  of  the  superintendent 
and  two  commissioners. 

A  cured  pauper,  on  discharge,  shall  have  a  good  suit  of  clothes  and  be 
furnished  with  money  not  exceeding  $20. 

In  order  to  relieve  the  asylum  from  having  too  many  patients,  all 
pauper  idiots,  epileptics,  and  harmless,  incurable  lunatics  shall  be  re- 
turned by  the  asylum  to  their  friends  or  to  the  several  counties  from 
which  they  were  sent.     A  commission,  consisting  of  the  president  of  the 

30 


466  APPENDIX  —  LOUISIANA. 

board  of  commissioners  of  each  asylum,  the  superintendent  and  one  other 
of  the  commissioners,  shall  investigate  and  determine  what  patients  are 
fit  to  send  back.  Such  patients  are  to  be  taken  care  of  either  by  their 
county  committee,  or  by  their  friends,  or  at  the  expense  of  the  State,  as 
the  case  may  be. 

Whenever  it  is  suggested  by  affidavit  to  the  court  having  jurisdiction, 
that  a  person  found  of  unsound  mind  has  been  restored  to  his  proper 
senses,  or  that  the  inquest  was  false  or  fraudulent,  the  court  shall  forth- 
with direct  the  facts  to  be  inquired  into  by  a  jury  in  open  court  and  make 
all  necessary  orders  in  the  premises. 

Any  patient  charged  with  crime  who  is  cured  of  his  insanity  shall  be 
delivered  to  the  keeper  of  the  penitentiary  or  jailor  of  the  county,  as  the 
case  may  require. 


LOUISIANA.' 


Whenever  it  shall  be  made  knoAvn  to  the  judge  of  the  district  or  parish 
court,  by  the  petition  and  oath  of  any  individual,  that  any  lunatic  or 
insane  person  within  his  district  ought  to  be  sent  to,  or  confined  in,  the 
Insane  Asylum  of  the  State,  said  judge  shall  issue  a  warrant  to  bring 
the  insane  person  before  him,  and,  after  proper  inquiry,  if,  in  his  opinion, 
he  ought  to  be  sent  to  the  asylum,  he  shall  have  him  taken  there  by  the 
sheriff". 

The  board  of  administrators  of  the  asylum  shall  have  authority  to 
receive  insane  persons  not  sent  by  a  district  or  parish  judge,  on  such 
terms  as  they  may  deem  fit,  and  money  so  received  shall  be  applied  to 
the  support  of  the  institution. 

All  persons  received  in  the  asylum  as  insane  shall  be  charged  not  less 
than  $10  a  month,  unless  the  police  jury  of  the  parish  from  which  the 
insane  person  came,  a  municipal  council,  if  from  a  city  or  town,  or  clerk 
of  the  court,  shall  certify  that  said  person  is  in  indigent  circumstances. 
The  clerk  of  the  court,  before  granting  such  a  certificate,  shall  summon 
witnesses,  and  make  an  examination,  and  give  or  refuse  the  certificate,  as 
each  case  may  require. 

Whenever  any  person  arrested  to  answer  for  any  crime  or  misde- 
meanor, before  any  court  of  the  State,  shall  be  acquitted  by  the  jury,  or 
shall  not  be  indicted  by  the  grand  jury,  by  reason  of  the  insanity  of  such 
person,  and  the  discharge  of  such  person  shall  be  deemed  by  the  court  to 
be  dangerous,  the  court  shall  commit  such  person  to  the  State  Insane 
Hospital,  or  to  any  similar  institution  in  any  parish  within  the  jurisdic- 
tion of  the  court,  there  to  be  detained  until  restored  to  his  right  mind  or 
duly  discharged.    The  physician  of  the  asylum  shall  examine  the  lunatic 

^  Voorhies'  Revised  Statutes  of  Louisiana,  1876,  pp.  427,  462-466, 


APPENDIX — ^MAINE.  467 

or  insane  person  sent  to  the  asylum  by  such  a  judge,  and  if,  in  his 
opinion,  the  person  is  only  feigning  insanity,  being  a  person  charged  with 
a  felonious  crime,  he  shall  report  to  the  board,  who  shall  investigate  the 
facts,  and  if  a  majority  think  he  should  not  be  admitted,  he  shall  be  sent 
to  jail,  and  the  proper  authorities  notified  ;  and  also  if  the  prisoner  is 
received  and  becomes  sane  while  in  the  asylum. 

Any  person  attempting  or  assisting  the  seduction  or  abduction  of  a 
patient  from  an  insane  asylum  shall  be  liable  to  a  fine  not  less  than  $50 
and  not  exceeding  f  500,  or  to  imprisonment  from  one  to  six  months,  or 
to  both,  at  the  discretion  of  the  court. 


MAINE. 


The  number  of  patients  who  can  be  accommodated  in  the  hospital 
shall  be  apportioned  among  the  towns  according  to  their  population.  If 
the  hospital  is  likely  to  be  crowded,  a  preference  shall  be  given  to  those 
towns  which  have  not  already  their  full  proportion  of  patients  accommo- 
dated. 

The  municipal  ofiicers  of  towns  shall  constitute  a  board  of  examiners, 
and,  on  complaint  in  writing  of  any  relative  or  justice  of  the  peace  of 
their  town,  they  shall  immediately  inquire  into  the  condition  of  any 
person  therein  alleged  to  be  insane.  The  evidence,  and  a  certificate  of 
at  least  two  respectable  physicians,  based  upon  due  inquiry  and  personal 
examination  of  the  person  to  whom  insanity  is  imputed,  shall  be  required 
to  establish  the  fact  of  insanity.  A  certified  copy  of  the  physicians' 
certificate  shall  accompany  the  person  to  be  committed.  If  the  board  of 
examiners  think  such  person  insane,  and  that  his  comfort  and  safety,  and 
that  of  others  interested,  will  thereby  be  promoted,  they  shall  forthwith 
send  him  to  the  hospital,  with  a  certificate  stating  his  insanity  and  his 
residence,  and  directing  the  superintendent  to  receive  and  detain  him. 
The  examiners  shall  keep  a  record  of  their  doings. 

Any  person  aggrieved  by  the  decision  of  the  board  of  examiners,  for 
or  against  insanity,  may  appeal  therefrom,  by  claiming  the  appeal  within 
five  days,  naming  a  justice  of  the  peace  and  quorum  on  his  part,  and 
appointing  a  time  within  three  days  thereafter,  and  a  place  in  such  town 
or  an  adjoining  town  for  the  hearing;  the  board  of  examiners  shall  select 
another  justice  of  the  peace  and  quorum. 

If  the  municipal  officers  applied  to  in  the  first  instance  neglect  for 
three  days  to  examine  into  and  decide  a  case,  or  if  the  two  justices 
selected  on  appeal  neglect  for  three  days  to  decide  the  appeal,  complaint 
may  be  made  by  any  relative  of  the  insane,  or  by  any  respectable  person, 

>  Commissioners'  Keport  on  Revision  of  the  Laws  of  Maine,  1881,  pp.  GO,  956, 1126, 
1126,  1155,  1163-1173.     Special  Acts  and  Resolves,  1883,  p.  155. 


468  APPENDIX — MAINE. 

to  two  justices  of  the  peace  and  quomm,  and  the  justices  selected  in 
either  of  the  above  modes  shall  summon  testimony,  and  hear  and  decide 
the  case.  If  they  find  the  person  insane,  and  the  case  a  proper  one, 
they  shall  make  a  certificate  for  his  commitment  to  the  hospital.  Such 
justices  shall  keep  a  record  of  their  doings.  When  such  justices  order  a 
commitment,  the  municipal  officers  of  the  town  where  the  insane  person 
resides,  or  such  other  person  as  the  justices  direct,  shall  attend  to  the 
carrying  out  of  such  order. 

The  officers  ordering  tile  commitment  of  a  person  unable  to  pay  for 
his  support  may  certify  to  the  trustees  that  fact,  and  that  he  has  no 
relatives  able  and  liable  to  pay  for  it.  In  such  cases  the  State  shall  pay 
$1.50  a  week  for  his  board,  and  the  balance  shall  be  paid  by  the  patient, 
or  by  the  town  where  he  resides. 

Parents  and  guardians  of  insane  minors,  if  of  sufficient  ability  to  sup- 
port them  in  a  hospital,  shall,  within  thirty  days  after  an  attack  of 
insanity,  send  them  to  the  State  Hospital,  or  to  some  other  hospital  for 
the  insane,  without  any  legal  examination.  All  other  persons  shall  be 
subject  to  examination.  Any  town  paying  for  the  commitment  and 
support  of  an  insane  person  may  receive  the  amount  from  him,  if  he  has 
property,  or  from  the  persons  legally  liable  for  his  support. 

When  any  man,  or  any  unmarried  woman  of  twenty-one  years  of  age, 
is  sent  to  the  Hospital  for  the  Insane,  the  municipal  officers  of  the  town, 
when  they  think  it  advisable,  may  apply  to  the  probate  judge,  and  have 
a  guardian  appointed  to  care  for  any  property  that  he  or  she  may  have, 
and  provide  for  the  support  of  the  insane  person  and  family. 

Patients  who  have  no  means  of  their  own  and  are  without  relatives 
liable  for  their  support,  if  they  belong  in  towns  having  less  than  two 
hundred  inhabitants,  shall  be  supported  in  the  hospital  at  the  expense  of 
the  State. 

When  any  friend,  person,  or  town,  liable  for  the  support  of  a  patient 
who  has  been  in  the  hospital  six  months,  not  committed  by  order  of  the 
Supreme  Judicial  Court,  nor  afflicted  with  homicidal  insanity,  thinks 
that  he  is  unreasonably  detained,  he  may  apply  to  the  municipal  officers 
of  the  town  where  the  insane  person  has  his  residence,  and  they  shall 
inquire  into  the  case  and  summon  testimony,  and  their  decision  shall  be 
-binding  on  the  parties.  If  such  application  is  unsuccessful,  it  shall  not  be 
made  again  until  the  expiration  of  another  six  months. 

At  the  annual  meeting  of  the  trustees,  they,  with  the  superintendent, 
shall  make  a  particular  examination  into  the  condition  of  each  patient 
and  discharge  any  one  so  far  restored  that  his  comfort  and  safety,  and 
that  of  the  public,  no  longer  require  his  confinement.  The  superin- 
tendent, at  each  monthly  visit  of  the  trustees,  shall  report  to  them  the 
name  of  any  inmate  who  was  idiotic  at  the  date  of  his  commitment,  and 
of  any  inmate  who  has  become  so  imbecile  as  in  his  judgment  to  be  beyond 
cure,  and,  if  he  thinks  such  inmate  may  be  discharged  with  safety  to  him- 
self and  to  the  public,  the  trustees  shall  order  his  discharge,  and  cause 
him  to  be  removed  by  the  town  by  which  he  was  committed.  If  any 
person  appears  to  have  been  unlawfully  committed,  the  superintendent 
shall  report  in  like  manner. 

The  Governor  shall  appoint  a  committee  of  visitors,  consisting  of  two 


APPENDIX — MAINE.  469 

members  of  the  executive  council  and  one  woman,  who  shall  make  visits 
as  often  as  once  a  month,  and  shall  correspond  with  the  patients,  and  shall 
report  all  abuses  and  ill-treatment,  and  see  that  the  same  are  properly 
dealt  with.  If  the  committee  of  visitors  shall  become  satisfied  that  any 
inmate  is  wrongly  committed  or  detained,  they  shall  apply  to  the  proper 
court  for  a  writ  of  habeas  corpus,  and  have  the  question  determined 
whether  such  inmate  is  a  proper  subject  for  custody  and  treatment.  But 
this  shall  not  apply  to  the  case  of  any  person  charged  with,  or  convicted 
of,  crime  and  duly  committed  by  order  of  court. 

When  any  person  is  indicted  for  an  offence,  or  is  committed  to  jail  on 
a  charge  thereof,  any  judge  of  the  court  before  which  he  is  to  be  tried, 
when  he  is  notified  that  a  plea  of  insanity  is,  or  will  be,  made,  may  order 
such  person  into  the  care  of  the  superintendent  of  the  insane  hospital,  to 
be  detained  and  observed  by  him  until  the  further  order  of  the  court,  that 
the  truth  or  falsity  of  the  plea  may  be  jiscertained.  Every  such  person 
so  committed  shall  be  discharged  by  the  superintendent  if  recovered,  if 
not  sent  for  by  the  court  during  the  next  term  thereof  after  his  com- 
mitment. 

When  the  grand  jury  omits  to  indict,  or  a  traverse  jury  acquits,  on 
account  of  the  insanity  of  the  accused,  the  court  may  commit  the  person 
to  the  insane  department  of  the  State  Prison,  or  to  the  insane  hospital. 
If  committed  to  the  insane  department  of  the  State  Prison,  he  shall  be 
discharged  only  on  satisfactory  proof  that  his  discharge  will  not  endanger 
the  peace  and  safety  of  the  community.  If  he  is  discharged  and  again 
becomes  insane,  any  judge  of  the  Supreme  Judicial  Court  may  recommit 
him  to  the  insane  department  of  the  State  Prison,  or  to  the  insane  hos- 
pital. If  committed  in  the  first  instance  to  the  insane  hospital,  he  may 
be  discharged  by  any  judge  of  the  Supreme  Judicial  Court,  if  his  dis- 
charge will  not  endanger  the  community  ;  or  the  judge  may,  on  applica- 
tion, commit  him  to  the  custody  of  any  friend  who  shall  give  bonds  to 
the  Probate  Judge  of  Kennebec  County  to  keep  such  insane  person  safely 
and  pay  for  all  damage  he  may  do.  If  such  person  again  becomes  dan- 
gerous, any  judge  of  the  Supreme  Judicial  Court  may  recommit  him  to 
the  insane  hospital. 

When  a  convict  is  thought  insane,  the  warden  or  jailor  shall  notify  the 
Governor,  who  shall  appoint  two  or  more  skilful  physicians  to  investigate 
the  case.  If  such  inmate  is  found  insane,  he  shall  be  sent  to  the  insane 
hospital,  to  be  kept  there  until  he  becomes  of  sound  mind.  If  he  recovers 
before  the  expiration  of  his  sentence,  he  shall  be  returned  to  prison.  If 
insane  convicts  prove  incurable  and  likely  to  have  a  deleterious  influence 
on  the  other  patients  of  the  hospital,  the  Governor  and  Council  may 
remove  them  to  the  insane  department  of  the  State  Prison. 

If  an  insane  person  is  arrested  on  civil  process,  a  writ  of  habeas  corpus 
may  be  had  to  obtain  his  discharge. 


470  APPENDIX — MARYLAND, 


MARYLAND.* 

Each  county  is  allowed  in  the  insane  hospital  its  due  share  of  inmates 
in  proportion  to  its  population.  Pay  patients,  to  a  number  not  exceeding 
seventy-five  at  any  one  time,  may  be  received.  Lunatics  and  insane 
persons  are  also  provided  with  accommodations  and  support  in  the 
county  almshouses,  and  in  the  almshouse  of  the  city  of  Baltimore.  A 
court  of  equity  may,  on  the  application  of  the  trustee  of  a  person  non 
compos  mentis,  if  satisfied  that  it  is  necessary  and  proper  to  confine  such 
person,  direct  that  he  be  sent  to  any  hospital  in  the  vicinity  of  the  city 
of  Baltimore,  there  to  remain  until  the  further  order  of  the  court. 

When  any  person  is  alleged  to  be  a  lunatic  or  insane  pauper,  the 
circuit  court  for  the  county  where  he  resides,  or  the  Criminal  Court  of 
Baltimore,  if  he  resides  there,  shall  cause  a  jury  of  twelve  men  to  be  im- 
panelled to  inquire  whether  such  person  is  insane  or  lunatic.  If  he  shall 
be  found  so,  the  court  shall  cause  him  to  be  sent  to  the  almshouse  of  the 
county  or  city  to  which  he  belongs,  or  to  a  hospital,  or  to  some  other 
place  better  suited  to  his  condition,  there  to  be  confined,  at  the  expense 
of  the  county  or  city,  until  he  has  recovered.  But  the  friends  or  relations 
of  such  lunatic  or  insane  person  are  not  prevented  from  confining  him  or 
providing  for  his  comfort. 

The  county  commissioners  of  any  county  may,  in  their  discretion,  re- 
move any  lunatic  pauper  from  the  almshouse  and  send  him  to  the  Hospital 
for  the  Insane,  and,  if  the  quota  allowed  such  county  is  already  filled,  the 
expense  of  such  lunatic  at  the  hospital  shall  be  paid  by  the  county.  No 
person  shall  be  supported  as  a  pauper  lunatic  if  he  has  any  property,  nor 
shall  a  person  who  is  living  with  his  parents  be  so  supported  if  they  have 
property  assessed  as  high  as  $1000. 

Private  patients  are  committed  to  an  asylum,  under  its  by-laws,  upon  the 
certificate  of  insanity  by  a  regular  physician,  sworn  to  before  a  magistrate, 
and  upon  the  request  of  some  responsible  person,  who  shall  give  bonds. 

If  a  person  under  indictment  or  charged  with  any  offence  is  alleged  to 
be  insane  or  a  lunatic,  and  it  is  found  by  the  jury  who  try  the  case,  or 
by  a  jury  summoned  to  inquire  into  the  insanity,  that  such  person  was 
insane  at  the  time  of  committing  the  offence,  and  still  is  so,  the  court  shall 
cause  such  person  to  be  sent  to  the  almshouse  of  the  county  or  city  to 
which  such  person  belongs,  to  a  hospital,  or  to  some  other  place  better 
suited  to  the  condition  of  the  prisoner,  there  to  be  confined  until  he  has 
recovered  his  reason  and  has  been  discharged  by  due  course  of  law. 

If,  during  the  recess  of  either  of  said  courts,  any  person  appearing,  or 
alleged  to  be,  insane  shall  be  arrested  and  charged  with  a  crime,  the  judge 
shall  have  a  jury  of  twelve  men  at  once  summoned  by  the  sheriff,  to  try 
the  question  whether  the  prisoner  was  insane  when  the  offence  was  com- 
mitted, and  still  is  so.  If  found  insane,  he  shall  be  committed  as  above 
stated. 

1  Kevised  Code  of  Maryland,  1878,  pp.  62,  242-244,  497-499,  660.  Laws  of  Mary- 
land, 1880,  p.  465. 


APPENDIX — MASSACHUSETTS.  471 

If  any  prisoner  thus  found  insane  has  property,  the  income  of  which  is 
sufficient  to  pay  for  his  support  in  a  hospital,  the  court  shall  appoint  a 
trustee  to  take  charge  of  such  estate  and  to  have  such  insane  person  con- 
fined and  supported  in  some  hospital  or  asylum. 

If  any  convict  in  the  Maryland  Penitentiary  is  insane,  the  Governor, 
on  recommendation  of  the  hoard  of  directors,  may  remove  him  and 
provide  for  his  support  and  safe  keeping  in  the  Hospital  for  the  Insane, 
or  in  any  other  State  institution  for  the  insane,  and  the  expense  shall 
be  paid  out  of  the  funds  of  the  penitentiary. 


MASSACHUSETTS.' 

A  judge  of  the  supreme  judicial  court,  or  superior  court,  in  any  county 
where  he  may  be,  and  a  judge  of  the  probate  court,  or  of  a  police,  district, 
or  municipal  court  within  his  county,  may  commit  to  either  of  the  State 
lunatic  hospitals  any  insane  person  then  residing  or  being  in  said  county, 
who,  in  his  opinion,  is  a  proper  subject  for  its  treatment  or  custody. 

Except  when  otherwise  specially  provided,  no  person  shall  be  committed 
to  a  lunatic  hospital,  or  other  receptacle  for  the  insane,  public  or  private, 
Avithout  an  order  or  certificate  signed  by  one  of  said  judges,  stating  that 
the  judge  finds  that  the  person  is  insane  and  is  a  fit  person  for  treatment 
in  an  insane  asylum.  The  judge  shall  see  and  examine  the  person  alleged 
to  be  insane,  or  shall  state  in  his  order  the  reason  why  it  was  not  deemed 
necessary.  The  judge  shall  in  all  cases  certify  in  what  place  the  lunatic 
resided  at  the  time  of  commitment.  There  must  be  filed  with  the  judge 
a  certificate  signed  by  two  physicians,  each  of  whom  is  a  graduate  of  some 
legally  organized  medical  college,  and  has  practised  three  years  in  the 
State,  and  neither  of  whom  is  connected  with  any  hospital  for  the  insane. 
Each  physician  must  have  personally  examined  the  person  alleged  to  be 
insane,  within  five  days,  and  each  shall  certify  on  oath  that  in  his  opinion 
the  person  is  insane  and  a  proper  subject  for  treatment,  giving  his  reason 
therefor.  A  copy  of  this  certificate  shall  be  sent  with  the  patient  to  the 
hospital. 

A  person  applying  for  the  commitment  of  a  lunatic  to  a  State  hospital 
shall  first  give  notice  to  the  mayor,  or  one  of  the  selectmen  of  the  place 
where  the  lunatic  resides,  of  his  intention  to  make  such  application.  In 
all  cases  there  shall  be  filed  with  the  application,  or  within  ten  days  after 
the  commitment,  a  statement  in  detail  in  prescribed  form,  giving  the 
history,  habits,  and  condition,  and  the  names  of  relatives,  not  exceeding 
ten  in  number,  of  the  patient.  This  statement,  or  a  copy  of  it,  shall  be 
sent  to  the  superintendent  of  the  asylum.     The  superintendent  shall  at 

1  Public  Statutes  of  Massachusetts,  1882,  pp.  432-434,  471,  472,  474-482,  949,  1197, 
1198,  1201,  1202,  1207,  1244.  Acts  and  Eesolves  of  Massachusetts,  1882,  p.  248; 
1883,  pp.  49,  77. 


472  APPENDIX — MASSACHUSETTS. 

once  cause  notice  to  be  sent  by  mail  to  each  of  said  relatives  of  the  fact 
of  the  patient's  admission,  and  also  to  any  other  two  persons  whom  the 
patient  shall  designate.  The  judge,  in  his  discretion,  may  apprehend  the 
alleged  insane  person  and  place  him  in  confinement  pending  examination, 
and  may  summon  a  jury  to  try  the  question  of  insanity.  The  verdict  of 
the  jury  shall  be  final. 

If  the  State  Board  of  Health,  Lunacy,  and  Charity  finds  an  insane 
person  not  incurable,  in  an  almshouse  or  other  place,  in  need  of  better 
treatment,  it  shall  cause  application  to  be  made  to  a  judge  for  his  commit- 
ment to  a  hospital. 

Any  person  whose  case  is  duly  certified  separately  by  two  physicians, 
qualified  as  above,  to  be  one  of  violent  and  dangerous  insanity,  may  be 
received  by  the  superintendent  of  any  lunatic  hospital  and  detained  not 
exceeding  five  days  without  any  warrant  of  commitment  by  a  judge.  In 
such  a  case  there  shall  be  an  application,  signed  by  one  of  the  selectmen 
of  the  town,  or  by  the  mayor  or  one  of  the  aldermen  of  the  city  where 
the  insane  person  resides,  stating  that  the  case  is  one  of  violent  and 
dangerous  insanity,  and  giving  the  facts  in  regard  to  the  patient's 
symptoms  and  history.  The  person  committing  such  a  person  shall  give 
a  bond  of  $100  dollars  that  he  will,  in  five  days,  obtain  a  regular  order 
of  commitment,  or  take  the  patient  away. 

The  superintendent  of  any  insane  hospital,  private  or  public,  may 
receive  and  detain  therein  as  a  boarder  and  patient  any  person  who  is 
desirous  of  submitting  himself  to  treatment,  and  makes  written  applica- 
tion therefor,  but  who  is  not  so  insane  as  to  make  it  proper  to  grant  a 
certificate  of  insanity.  Such  patient  shall  not  be  detained  longer  than 
three  days  after  having  given  notice  in  writing  of  his  desire  to  leave. 
When  such  a  patient  is  admitted,  notice  shall  at  once  be  given  to  the 
State  Board  of  Health,  Lunacy,  and  Charity,  who  shall  cause  the  case  to 
be  investigated. 

Pauper  lunatics  having  no  known  settlement  shall  be  supported  at  the 
expense  of  the  State ;  other  pauper  lunatics  by  the  towns  or  cities  where 
their  settlement  is.  Amounts  paid  by  the  State,  or  by  a  city  or  town, 
may  be  recovered  of  any  person  legally  liable  to  support  the  lunatic. 

The  attorney  of  a  patient  shall  be  allow^ed  to  visit  him  in  the  hospital 
at  all  reasonable  times,  if  his  visits,  in  the  opinion  of  the  superintendent, 
would  not  be  injurious  to  the  patient,  or  upon  the  order  of  a  judge  of  the 
supreme,  superior,  or  probate  court.  Patients  shall  be  furnished  materials 
to  write  monthly  to  the  superintendent  and  to  the  State  Board ;  and 
locked  letter-boxes  shall  be  provided  in  each  ward,  to  be  opened  monthly 
by  the  State  Board. 

The  State  Board  of  Health,  Lunacy,  and  Charity,  shall  have  general 
supervision  over  the  hospitals  for  the  insane,  public  and  private,  and 
shall  act  as  commissioners  of  lunacy,  with  power  to  discharge  any  person, 
whether  insane  or  not,  who  is  improperly  restrained  of  his  liberty,  in 
their  opinion,  by  reason  of  alleged  insanity.  It  may  discharge  also  such 
patients  as  can  be  cared  for  after  such  discharge  without  danger  to  others 
and  with  benefit  to  themselves.  The  Board  may,  when  directed  by  the 
Governor,  assume  and  exercise  the  powers  of  the  board  of  trustees. 

Any  two  of  the  trustees  of  a  State  lunatic  hospital,  or  any  judge  of  the 


APPENDIX — Massachusetts:  473 

supreme  judicial  court,  or  the  judge  of  the  probate  court  for  the  county 
in  which  the  hospital  is  situated,  or  in  which  the  patient  had  his  resi- 
dence, after  such  notice  as  the  said  trustees  or  judge  may  deem  reason- 
able and  proper,  may  discharge  any  patient,  if  it  appears  that  he  is  not 
insane,  or,  if  insane,  will  be  sufficiently  provided  for  by  himself,  his  rela- 
tives, or  friends,  or  by  the  city  or  town  liable  for  his  support,  or  that  his 
confinement  is  no  longer  necessary  for  the  safety  of  the  public  or  his 
own  welfare.  Any  two  of  the  trustees  may  remove  to  the  town  or  city 
from  which  he  came  any  patient  who  is  incurable  and  is  not  dangerous. 

Any  person  may  apply  to  a  judge  of  the  supreme  judicial  court,  stating 
that  he  has  reason  to  believe  that  a  person  named  is  confined  as  insane 
in  a  lunatic  hospital,  or  other  place,  public  or  private,  and  ought  not 
longer  to  be  so  confined,  and  requesting  his  discharge.  Such  judge,  if 
he  thinks  it  proper,  shall  appoint  a  hearing  and  give  notice  of  it  to  the 
superintendent,  and  to  such  other  persons  as  he  deems  proper.  The 
alleged  insane  person  may  be  brought  personally  before  the  judge  by  a 
writ  of  habeas  corpus,  if  it  is  requested,  and  he  thinks  it  proper.  On 
the  request  of  any  person  interested,  the  question  shall  be  submitted  to 
a  jury.  If  it  is  found  by  the  jury,  or  by  the  judge  if  it  is  not  submitted 
to  a  jury,  that  the  person  is  not  insane,  or  ought  not  to  be  so  confined, 
he  shall  be  discharged  from  such  confinement. 

No  pauper  shall  be  discharged  from  a  State  hospital  without  suitable 
clothing,  and  the  trustees  may  fiirnish  him  with  a  sum  of  money  not  ex- 
ceeding $20. 

The  Governor  or  the  State  board  may  transfer  inmates  from  one  State 
hospital  to  another  when  it  is  necessary  or  advisable. 

The  State  board  also  may  remove  any  inmate  of  the  State  Almshouse 
or  State  Workhouse  to  either  of  the  State  lunatic  hospitals,  if  his  condi- 
tion requires  such  transfer.  But  no  such  transfer  shall  be  made  without 
the  certificate  of  two  physicians,  one  of  whom  has  no  connection  with  any 
insane  hospital,  to  the  insanity  of  such  inmate. 

Transfers  from  one  private  asylum  to  another,  or  from  a  private  asylum 
to  a  State  lunatic  hospital,  may  be  made  with  the  consent  of  the  State 
Board,  but  no  such  transfer  shall  be  made  without  the  consent  of  the 
legal  or  natural  guardian  of  such  inmate. 

If  all  the  State  lunatic  hospitals  are  crowded,  the  trustees  of  any  one 
may  remove  to  their  homes,  or  places  of  legal  settlement,  so  many  of 
those  who  are  incurable  and  can  be  suitably  managed  at  home  as  may  be 
necessary  to  make  sufficient  room. 

Patients  not  furiously  mad  may  be  committed  by  any  judge  authorized 
to  act  to  the  county  receptacle,  which  is  required  by  law  for  each  county, 
either  within  the  precincts  of  the  house  of  correction,  or  in  another 
building  to  be  deemed  a  part  of  the  house  of  correction. 

Any  insane  person  confined  in  a  jail,  house  of  correction,  or  county 
receptacle,  may  be  removed  by  the  Governor  to  either  of  the  State 
lunatic  hospitals,  or  to  any  other  jail,  or  to  any  other  suitable  place, 
whenever  it  seems  expedient  and  just. 

Any  person  committed  to  a  county  receptacle  as  not  furiously  mad 
may  be  discharged  by  the  judge,  if  it  appears  to  be  for  the  patient's 


474  APPENDIX  —  MASSACHUSETTS. 

benefit,  or  when  it  appears  that  he  can  be  comfortably  cared  for  by  friends 
or  kindred. 

Dangerous  lunatics  shall  not  be  sent  to  the  State  Almshouse. 

The  board  of  trustees  of  any  of  the  State  lunatic  hospitals  may  give 
the  superintendent  authority  to  discharge  any  inmate  committed  thereto, 
as  an  insane  person,  but  notice  of  the  intention  to  discharge  must  be  sent 
by  the  superintendent  to  the  person  or  persons  who  signed  the  petition 
for  the  commitment  of  such  inmate.  The  superintendent  may  also,  if 
he  deem  it  advisable,  allow  inmates  to  leave  the  hospital  temporarily  in 
charge  of  their  friends  for  a  period  not  exceeding  sixty  days,  and  may 
receive  such  patients  back  without  any  further  order  of  commitment. 

When  a  person  confined  in  jail  on  civil  process  is  supposed  to  be  in- 
sane, so  as  to  be  incapable  of  taking  the  poor  debtors'  oath,  any  person 
interested  may  apply  to  the  judge  of  probate  for  the  county  in  which  he 
is  imprisoned.  The  judge  shall  appoint  a  hearing,  give  notice  to  the 
creditor  or  his  attorney,  and  proceed  with  an  examination  into  the  ques- 
tion of  insanity  in  the  regular  manner.  If  the  person  is  found  insane, 
the  judge  may  order  his  discharge,  or  his  removal  to  one  of  the  State 
lunatic  hospitals,  or  other  place,  for  the  confinement  of  insane  persons. 

If  the  grand  jury  fail  to  indict  a  man  by  reason  of  his  insanity,  the 
court,  or  a  judge  of  the  supreme  court,  sitting  for  the  arraignment  of  a 
person  charged  with  murder,  if  satisfied  that  he  is  insane,  may  order  him 
to  be  committed  to  a  State  lunatic  hospital. 

When  a  person  indicted  is  at  the  time  appointed  for  the  trial  found  to 
the  satisfaction  of  the  court  to  be  insane,  the  court  may  cause  him  to  be 
removed  to  one  of  the  State  lunatic  hospitals. 

If  a  person  convicted  of  a  capital  crime,  but  not  yet  sentenced,  is  found 
to  the  satisfaction  of  the  court  to  be  insane,  he  may  be  removed  to  one  of 
the  State  lunatic  hospitals. 

If  a  person  convicted  and  sentenced  to  death  appears  to  the  satisfac- 
tion of  the  Governor  and  Council  to  have  become  insane,  they  may  respite 
the  execution  from  time  to  time,  until  it  appears  that  the  convict  is  no 
longer  insane. 

A  person  acquitted  of  a  crime,  other  than  murder  or  manslaughter,  by 
a  jury  on  the  ground  of  insanity,  may  be  committed  to  an  insane  asylum 
by  the  court,  if  satisfied  of  the  insanity. 

When  a  convict  in  the  State  Prison  or  Woman's  Reformatory  Prison 
appears  to  be  insane,  he  may  be  removed,  by  order  of  the  Governor,  to 
one  of  the  State  lunatic  hospitals.  Such  convict,  however,  shall  first  be 
examined  by  a  person  expert  in  cases  of  insanity  appointed  by  the  State 
Board  of  Health,  Lunacy,  and  Charity,  and  also  by  the  physician  of  the 
prison. 

If  he  recovers  his  sanity  before  his  term  of  imprisonment  has  expired, 
he  shall  be  reconveyed  to  the  prison. 

When  a  convict  in  a  house  of  correction  or  prison  other  than  the  State 
Prison  or  Reformatory  Prison  appears  to  be  insane,  the  case  shall  be 
reported  by  the  physician  to  the  jailer  or  keeper,  and  by  him  to  one  of 
the  judges  authorized  to  act  in  cases  of  insanity,  and  the  regular  pro- 
ceedings shall  be  had  for  committing  such  person  to  an  insane  hospital. 


APPENDIX  —  MICHIGAN.  475 

If  he  recovers  before  the  expiration  of  his  sentence,  he  shall  be  returned 
to  the  prison  or  house  of  correction. 

Persons  held  in  jail  for  trial  or  for  sentence,  except  for  a  capital  crime, 
may,  if  found  insane,  be  committed  to  one  of  the  State  lunatic  hospitals, 
there  to  remain  until  restored  to  sanity. 

When  a  person  indicted  for  murder  or  manslaughter  is  acquitted  by 
reason  of  insanity,  the  court  shall  order  such  person  to  be  committed  to 
one  of  the  State  lunatic  hospitals  during  his  life.  He  may  be  discharged 
therefrom  by  the  Governor,  with  the  consent  of  the  council,  if  he  becomes 
no  longer  dangerous. 

Any  physician  wilfully  conspiring  to  commit  any  person  Avho  is  not 
insane  to  any  hospital  or  asylum  in  the  State  shall  be  punished  by  fine 
or  imprisonment.  Any  person  who  establishes  or  keeps  a  private  insane 
asylum  without  a  license  from  the  Governor  or  council,  unless  otherwise 
authorized  by  law,  shall  forfeit  a  sum  not  exceeding  ^500. 


MICHIGAN.' 


When  a  person,  indigent,  but  not  a  pauper,  appears  to  be  insane, 
application  may  be  made  to  the  judge  of  probate  of  the  county  where  he 
resides.  The  judge  shall  appoint  a  time  for  a  hearing,  and  notify  the 
alleged  insane  person.  He  shall  call  two  respectable  physicians  and 
other  Avitnesses,  and  shall  notify  the  prosecuting  attorney  of  the  county 
and  the'  supervisor  of  the  township  or  ward  where  the  insane  person 
resides,  whose  duty  it  shall  be  to  attend.  If  the  judge,  after  a  full  inves- 
tigation, either  with  or  without  the  verdict  of  a  jury,  at  his  discretion, 
shall  find  him  insane  and  also  indigent,  he  shall  make  a  certificate,  and 
the  patient  shall  be  admitted  into  the  asylum  and  supported  there  at  the 
expense  of  his  county  until  he  is  cured,  if  his  cure  is  effected  within  two 
years,  and  until  otherwise  ordered.  The  judge  of  probate  shall  notify 
the  supervisors  of  his  county  of  the  result  of  the  proceedings,  and  they 
shall  raise  the  money  required  for  the  patient's  support. 

If  a  pauper  becomes  insane,  the  county  superintendents  of  the  poor,  or 
any  supervisor  of  any  city  or  town  where  the  pauper  belongs,  shall  make 
application  to  the  probate  judge  of  the  county,  who  shall  make  an  inves- 
tigation and  shall  call  one  or  more  respectable  physicians  and  other 
Avitnesses,  and,  if  satisfied  of  the  pei'son's  insanity,  shall  make  a  certifi- 
cate and  have  him  sent  to  the  insane  asylum,  as  in  the  case  of  a  person 
in  indigent  circumstances.  No  insane  person,  not  a  criminal,  shall  be 
confined  in  any  jail  more  than  ten  days,  nor  for  any  time  in  the  same 

1  Compiled  Laws  of  Michisran,  1871,  Vol.  II.  pp.  1482,  2167,  2168,  2178,  2196. 
Laws  of  Michigan,  1873,  pp.  226.  227;  1877,  p.  120.  Howell's  Annotated  Statutes, 
Michigan,  1882,  Vol.  I.  pp.  513-530. 


476  APPENDIX — MICHIGAN. 

room  with  a  person  charged  with,  or  convicted  of,  crime.  When  an 
indigent  insane  person  has  been  sent  to  the  asylum  by  his  friends  who 
have  paid  his  bills  there  for  three  months,  if  the  superintendent  certify 
that  he  is  a  fit  patient,  the  supervisors  of  the  county  of  his  residence  are 
required  to  defray  the  expenses  of  his  remaining  thereafter.  Extra  care 
and  attendance  may  be  allowed  patients  if  specially  contracted  for. 

The  toAvn  or  county  ofiicers  sending  a  patient  to  the  asylum,  shall  pro- 
vide during  the  removal  a  female  attendant  to  every  female  patient,  unless 
accompanied  by  her  husband,  father,  brother,  or  son. 

If  a  patient  has  no  legal  settlement  in  any  county  or  township,  the 
expense  of  his  support  in  the  asylum  shall  be  paid  by  the  State. 

The  probate  judge  committing  any  indigent  insane  person  or  insane 
pauper  shall  inquire  ihto  and  determine  whether  he  has  a  legal  settlement 
and  where  it  is. 

The  trustees  of  the  different  asylums  shall  meet  jointly  once  or  more 
each  year,  and  may  transfer  patients  from  one  hospital  to  another  if  it  is 
necessary  or  desirable. 

So  long  as  there  is  room  for  the  insane  in  the  wards  of  the  State 
asylums,  it  shall  be  illegal  to  consign  any  insane  person  to  the  county 
almshouses. 

No  patient  shall  be  discharged  without  suitable  clothing,  and  if  not 
otherwise  provided,  the  steward  shall  furnish  it,  and  also  money  not 
exceeding  $20. 

When  a  person  shall  have  escaped  indictment,  or  shall  have  been 
acquitted  of  a  criminal  charge  or  a  misdemeanor  on  the  ground  of  insanity, 
the  court  shall  carefully  inquire  and  ascertain  whether  his  insanity  in 
any  degree  continues,  and,  if  it  does,  shall  order  him  in  safe  custody  and 
to  be  sent  to  the  asylum. 

If  any  person  in  confinement  under  indictment,  or  sentence  of  impris- 
onment, or  on  any  criminal  process  whatever,  shall  appear  to  bg  insane, 
the  circuit  court  commissioner  of  the  county  where  he  is  confined,  or,  if 
he  be  absent,  the  judge  of  the  circuit  court,  shall  upon  the  application  of 
the  prosecuting  attorney  institute  an  investigation  and  call  two  respectable 
physicians.  If  the  insanity  is  proved,  the  commissioner  or  judge  may 
order  the  safe  custody  and  removal  of  such  person  to  the  asylum,  there  to 
remain  until  restored  to  sanity.  If  the  patient  recovers,  he  shall  be  sent 
back  to  prison  to  be  proceeded  against  criminally,  kept  in  confinement,  or 
discharged,  as  the  case  may  be. 

If  a  person  imprisoned  on  civil  process  becomes  insane,  like  proceed- 
ings shall  be  resorted  to,  but  notice  shall  be  given  to  the  plaintiff  or  his 
attorney,  if  in  the  State. 

An  insane  criminal  may  be  discharged  by  order  of  one  of  the  justices 
of  the  supreme  court  or  a  circuit  judge  when,  upon  due  investigation,  it 
appears  safe,  legal,  and  right,  to  make  such  order. 

All  insane  soldiers  and  marines  of  the  State  shall  be  removed  to  the 
insane  hospitals,  and  there  provided  for  at  the  expense  of  the  State. 

If  any  convict  shall  show  symptoms  of  insanity  while  serving  sentence, 
the  warden  shall  give  notice  to  the  physician  of  the  prison  and  to  the 
medical  superintendent  of  the  insane  asylum  at  Kalamazoo.  They  shall 
forthwith  examine  such  convict,  and,  if  they  find  him  insane,  shall  certify 


APPENDIX — MINNESOTA.  477 

the  fact  to  the  warden,  who  shall  forthwith  put  the  convict  in  the  insane 
department  of  the  prison,  and  notify  the  Governor  of  his  condition.  The 
Governor  shall  inquire  into  the  facts,  and  may  order  the  lunatic  to  be 
conveyed  to  one  of  the  State  asylums  for  the  insane.  If  the  convict 
recovers  his  sanity  before  his  term  of  sentence  has  expired,  he  shall  be 
I'eturned  to  the  prison  to  serve  out  the  unexpired  time.  If  the  Governor 
does  not  order  the  removal  of  such  convict  to  the  insane  asylum,  the 
physician  of  the  prison  shall  give  him  such  treatment  as  circumstances 
will  permit  in  the  insane  department  of  the  prison.  If  the  convict  so 
treated  recovers  his  sanity,  or  so  far  recovers  that  it  is  safe  for  him  to 
work,  the  warden  shall  put  him  at  hard  labor  according  to  his  sentence. 

If  a  convict  at  the  expiration  of  his  term  of  sentence  is  deemed  insane, 
and  is  so  certified  by  the  physician  of  the  prison,  and  none  of  his  friends 
or  relatives  appear  to  take  charge  of  him,  the  warden  or  officer  in  charge 
shall  give  notice  to  the  county  clerk  of  the  county  from  which  the  convict 
was  sent,  and  to  one  or  more  relatives  or  friends  of  the  prisoner,  and  also 
to  the  probate  judge  of  the  county  where  the  prison  is  located.  The 
probate  judge  shall  order  the  sheriff  of  the  county  to  receive  the  convict 
on  his  discharge  and  bring  him  before  him.  The  judge  shall  then  call 
two  respectable  physicians  and  other  witnesses,  and  shall  notify  the  prose- 
cuting attorney  of  his  county,  whose  duty  it  shall  be  to  appear  and  act 
in  behalf  of  the  State,  The  judge  shall  fully  investigate  the  facts, 
either  with  or  without  a  jury,  and,  if  he  finds  the  person  insane  and  no 
relative  or  friend  ready  to  take  charge  of  him,  he  shall  send  him  to  one 
of  the  insane  asylums  of  the  State,  to  be  kept  until  restored  to  sanity,  or 
taken  charge  of  by  his  friends  or  otherwise  discharged. 

If  such  person  is  indigent  and  without  relatives,  liable  for  his  support, 
he  shall  be  supported  in  the  asylum  at  the  expense  of  the  State. 

Whenever  a  person  on  trial  for  murder,  or  assault  with  intent  to 
commit  murder,  or  arson,  pleads  insanity,  and  is  acquitted  and  found  by 
the  jury  not  guilty  by  reason  of  insanity,  he  shall  be  committed  to  the 
insane  hospital  connected  with  the  State  prison.  Such  person  shall  only 
be  released  on  the  certificate  of  the  medical  superintendent  of  the  insane 
asylum  at  Kalamazoo,  and  the  circuit  judge  of  the  court  which  committed 
him,  stating  that  he  has  so  far  recovered  as  to  be  safe  to  go  at  large.  On 
the  filing  of  such  a  certificate  with  the  Governor,  he  shall  order  the 
person  to  be  discharged. 


MINNESOTA. 


Any  insane  person  a  resident  of  the  State  may  be  admitted  to  the 
hospitals  and  maintained  at  the  public  expense,  free  of  charge  to  his  or 
her  relatives  or  friends,  and  all  shall  be  treated  as  public  patients.     The 

•  Statutes  of  Minnesota,  1878,  pp.  4.54-460,  598,  958.     Laws  of  Minnesota,  1879, 
pp.  26,  38,  39. 


478  APPENDIX — MINNESOTA. 

probate  judge,  or,  in  his  absence,  the  court  commissioner  of  any  county, 
upon  information  being  filed  before  him  that  there  is  an  insane  person 
in  his  county  needing  care  and  treatment,  shall  cause  the  person  alleged 
to  be  insane  to  be  examined  by  a  jury  consisting  of  two  respectable 
persons  beside  himself,  one  at  least  of  whom  shall  be  a  physician,  to 
ascertain  the  fact  of  insanity.  If  the  person  is  found  insane,  a  warrant 
shall  issue  directing  that  he  be  carried  by  the  sheriff  or  some  other  suit- 
able person,  and  placed  in  the  care  of  the  superintendent  of  the  insane 
hospital.  It  is  the  duty  of  the  judge  of  probate,  or  court  commissioner, 
with  the  assistance  of  the  examining  physician,  to  obtain,  so  far  as 
possible,  answers  to  certain  prescribed  questions  relating  to  the  history 
and  condition  of  the  patient,  and  to  forward  the  same  to  the  superinten- 
dent, when  the  patient  is  sent  to  the  hospital. 

Patients  shall  be  legally  discharged  by  vote  of  the  trustees,  and,  for 
this  purpose,  three  shall  constitute  a  quorum.  When  a  patient  is  dis- 
charged as  cured,  tne  superintendent  shall  furnish  him  with  suitable 
clothing  and  money  sufficient  to  pay  his  expenses  home,  unless  otherwise 
supplied. 

The  relatives  of  any  person  charged  with  insanity  or  found  to  be  in- 
sane shall  have  a  right  to  take  charge  of  and  keep  said  insane  person  if 
they  shall  desire  to  do  so ;  but  the  probate  judge  or  court  commissioner 
may  require  a  bond  of  such  relatives  for  the  proper  and  safe  keeping  of 
such  person.  If  the  relatives  or  friends  of  any  patient  kept  in  the  hos- 
pital shall  ask  for  his  discharge,  the  superintendent  may  require  a  bond 
conditioned  for  the  safe  keeping  of  such  patient :  Provided,  that  no 
patient  under  the  charge  of,  or  convicted  of,  homicide  shall  be  discharged 
without  the  consent  of  the  superintendent  and  board  of  trustees.  When- 
ever a  patient  is  discharged  from  either  asylum,  the  superintendent  shall 
send  notice  of  the  same  to  the  judge  of  probate  who  issued  the  warrant 
for  the  commitment. 

The  superintendent  of  each  hospital  is  required,  once  a  month,  to 
make  out  a  written  report  of  the  condition  of  each  patient  in  the  hospital, 
and  to  send  a  copy  to  the  next  of  kin  of  each  of  said  patients. 

A  commission  appointed  by  the  Governor,  consisting  of  three  physi- 
cians, of  whom  one  shall  be  a  member  of  the  State  Board  of  Health, 
shall  visit  the  hospitals  for  the  insane  once  in  every  six  months,  or  at  the 
request  of  the  Governor,  to  examine  their  sanitary  and  general  condition, 
and  to  inquire  into  the  condition  of  the  patients,  and  make  a  report  in 
detail  to  the  Governor,  This  commission,  if  they  find  patients  whose  in- 
sanity they  have  reason  to  doubt,  may  remand  them  to  the  probate  courts 
by  which  they  were  committed,  to  be  there  detained  under  proper  surveil- 
lance until  the  judge  is  satisfied  of  their  sanity  or  insanity.  If  any  patient 
is  thus  found  to  be  sane,  he  shall  be  discharged  by  the  probate  court ;  other- 
wise he  shall  be  recommitted  to  the  hospital ;  but  no  person  charged  with 
a  crime  shall  be  so  discharged.  Idiots  and  feeble-minded  children  may 
be  removed  by  the  commissioners  and  sent  to  the  Asylum  for  the  Deaf, 
Dumb,  and  Blind,  to  be  there  treated. 

When  any  person  indicted  for  an  offence  is  on  trial  acquitted  by  reason 
of  insanity,  if  the  discharge  or  going  at  large  of  such  person  is  considered 
by  the  court  dangerous  to  the  community,  the  court  may  order  him  to  be 


APPENDIX — MISSISSIPPI.  479 

committed  to  the  Hospital  for  the  Insane  for  safe  keeping  and  treatment, 
or  may  order  him  to  be  committed  to  prison,  or  may  give  him  into  the 
care  of  his  friends,  taking  bonds  that  he  be  well  and  securely  kept. 

Whenever  a  convict  in  the  State  Prison  shall,  in  the  opinion  of  the 
warden  and  board  of  inspectors  thereof,  be  regarded  as  insane,  it  shall  be 
the  duty  of  said  board  to  call  in  two  skilled  physicians,  one  of  whom  may 
be  the  prison  physician,  who  shall,  without  employing  cruel  or  inhuman, 
tests,  make  a  careful  examination  as  to  the  insanity  of  such  convict,  and 
render  a  report,  to  be  entered  on  the  prison  records.  If  the  convict  is 
found  insane,  the  board  shall  notify  the  Governor,  who  shall  have  the 
prisoner  sent  to  the  insane  hospital,  there  to  be  kept  and  treated.  If 
such  a  patient  is  cured  of  the  mental  disability  on  account  of  which  he 
was  committed  to  the  hospital,  and  his  term  of  sentence  has  not  expired, 
the  Governor  shall  be  notified,  and  the  convict  shall  be  remanded  to  the 
State  Prison. 


MISSISSIPPI.^ 


Any  person,  being  a  lunatic  and  a  resident  of  the  State,  may  be  ad- 
mitted into  the  asylum  free  of  charge,  the  expenses  of  removal  to  be  paid 
by  the  county  from  which  the  insane  person  was  sent,  or  in  which  he  had 
his  settlement;  but  if  the  patient  is  able,  he  shall  pay  for  the  expense  of 
his  removal.  The  superintendent  of  the  asylum,  provided  there  is  room, 
shall  admit  all  persons  ordered  to  be  placed  therein  by  the  chancery 
court  after  an  inquest  of  lunacy. 

When  an  application  is  made  by  the  friends  or  relatives  of  a  lunatic 
to  the  chancery  court,  if  the  court  is  satisfied  there  is  probable  cause, 
it  shall  order  the  sheriff  to  summon  the  person  alleged  to  be  of  unsound 
mind,  and  six  good  men  of  the  county  in  no  way  related  to  the  party,  to 
try  the  question  of  insanity.  If  the  person  is  judged  by  the  inquest,  or 
a  majority  of  them,  to  be  incapable  of  taking  care  of  himself,  they  shall 
certify  the  same  to  the  court,  and  the  court  or  chancellor,  or  clerk  in 
vacation,  shall  appoint  some  suitable  person  guardian  of  such  lunatic, 
directing  the  guardian  to  take  care  of  the  person  and  his  estate.  If  the 
case  requires  it,  the  coui't  or  clerk  may  direct  confinement  in  the  lunatic 
asylum. 

In  case  the  friends  or  relations  of  any  lunatic  shall  neglect  or  refuse 
to  place  him  in  the  asylum,  and  shall  allow  him  to  go  at  large,  the  clerk 
of  the  chancery  court  of  any  county  in  which  such  lunatic  may  reside 
or  be  found  going  at  large,  on  the  suggestion,  in  writing,  of  any  citizen, 
shall  direct  the  sheriff  to  summon  the  lunatic  and  six  discreet  persons 
to  make  inquisition.     If  the  person  is  adjudged  by  the  inquest,  or  a 

I  Kevised  Code  of  Mississippi,  1880,  pp.  205-210,  581-583,  794,  795,  802,  803. 
Laws  of  Mississippi,  1882,  pp.  61-65. 


480  APPENDIX  —  MISSOURI. 

majority  of  them,  to  be  insane,  and  a  fit  subject  for  the  asylum,  the 
clerk  shall  order  the  sheriff"  to  take  the  lunatic  and  place  him  in  the 
asylum,  if  there  be  a  vacancy,  or,  if  there  be  no  vacancy,  to  confine  him 
in  the  county  jail  until  room  can  be  had  in  the  asylum. 

If  any  patient  is  found  incurable,  but  harmless,  the  superintendent 
shall  have  him  removed  to  the  county  where  he  belongs,  there  to  be  cared 
for  by  his  guardian  or  his  friends,  or,  if  he  is  poor  and  has  no  friends 
who  are  able,  he  shall  be  maintained  as  a  poor  person  by  the  county. 

If  the  superintendent  and  trustees  think  that  a  lunatic  who  is  a  resi- 
dent of  the  State  ought  to  be  admitted  as  a  patient,  they  may  receive 
him,  even  though  no  proceedings  in  lunacy  have  been  instituted.  The 
trustees  may  adopt  such  rules  as  they  think  proper  in  regard  to  requiring 
a  statement  of  the  case  and  a  history  of  the  patient,  to  be  presented  with 
the  application  for  admission. 

When  a  person  is  charged  with  the  commission  of  an  offence,  and  it 
appears  that  he  was  insane  when  the  offence  was  committed,  and  still  is 
insane,  he  shall  not  be  discharged,  but  the  case  shall  be  reported  to  the 
chancellor  or  clerk  of  the  chancery  court  of  the  proper  county,  whose 
duty  it  shall  be  to  proceed  with  the  case  according  to  the  law  relating  to 
persons  non  compos  mentis. 

When  the  grand  jury  fails  to  indict,  or  a  traverse  jury  fails  to  convict, 
a  person  by  reason  of  his  insanity,  and  it  is  found  that  the  person  is  still 
insane  and  dangerous,  notice  shall  be  given  to  the  proper  chancellor  or 
clerk  of  the  chancery  court,  whose  duty  it  shall  be  to  proceed  with  such 
person  and  his  estate  according  to  the  law  relating  to  insane  person. 

If  the  sheriff"  is  satisfied  that  any  convict  under  sentence  of  death  is 
insane,  he  shall,  wdth  the  concurrence  of  the  judge  of  the  circuit  court, 
or  the  chancellor,  or  the  president  of  the  board  of  county  supervisors,  in 
the  absence  of  such  circuit  judge,  summon  six  physicians,  if  to  be  had, 
and,  if  not,  six  other  discreet  men,  to  inquire  into  such  insanity.  If  the 
convict  is  found  insane,  the  verdict  shall  be  transmitted  to  the  Governor, 
and  the  execution  suspended  until  the  Governor  is  satisfied  that  the 
convict  has  become  sane. 


MISSOURI. 


Persons  afflicted  with  any  form  of  insanity  may  be  admitted  into  an 
insane  asylum  when  the  superintendent  thinks  they  will  be  benefited  by 
the  care  and  treatment  of  the  institution ;  and  any  patient  may  be  dis- 
charged by  the  superintendent  if  longer  treatment  is  not  likely  to  improve 
his  condition.  The  indigent  insane  of  the  State  shall  always  have  the 
preference  over  those  who  have  the  ability  to  pay,  and,  if  there  is  not 

1  Kevised  Statutes  of  Missouri,  1879,  Vol.  I.  p.  325;  Vol.  II.  pp.  818-828, 1133, 1138. 
Laws  of  Missouri,  1881,  pp.  123,  141;  1883,  pp.  78,  79. 


APPENDIX  —  MISSOURI.  481 

room  in  the  asylum  for  all  the  insane  persons  in  the  State,  recent  cases 
(of  less  than  a  year's  standing)  shall  have  the  preference ;  but  no  county 
shall  have  in  the  institution  more  than  its  just  proportion,  according  to 
its  insane  population.  There  shall  be  sent  with  each  patient  a  detailed 
account  of  his  case,  as  far  as  practicable,  stating  the  cause  of  his  insanity, 
its  duration,  the  former  treatment  of  the  patient,  and  all  other  particu- 
lars; and,  if  possible,  some  one  acquainted  with  the  individual  should 
accompany  him  to  the  asylum,  from  whom  minute  particulars  of  his  in- 
sanity may  be  learned. 

Pay  patients,  those  not  sent  by  order  of  the  court,  are  admitted  as 
follows :  The  superintendent  shall  be  furnished  with  a  request  in  a  pre- 
scribed form,  and  with  a  certificate,  dated  within  two  months,  in  pre- 
scribed form,  signed  by  two  physicians,  stating  the  patient  to  be  insane. 
Thirty  days'  charges  must  be  paid  in  advance,  and  a  suflScient  bond 
given  in  prescribed  form  to  secure  future  expenses,  and  the  removal  of 
the  patient  when  desired. 

County  patients  are  admitted  as  follows:  The  several  county  courts 
shall  have  power  to  send  to  the  asylum  such  of  their  insane  poor  as  may 
be  entitled  to  admission.  The  counties  thus  sending  shall  pay  semi- 
annually, in  cash,  in  advance,  for  the  support  of  their  insane  poor,  the 
price  of  board  to  be  fixed  by  the  board  of  managers.  Some  citizen  in 
the  proper  county  must  file  with  the  clerk  of  the  county  court  a  state- 
ment, in  prescribed  form,  that  the  person  is  insane  and  a  recent  case, 
and  has  no  property.  It  shall  give  the  names  of  two  witnesses  who  can 
swear  to  the  facts,  one  of  whom  shall  be  a  respectable  physician.  The 
clerk  shall  thereupon  summon  the  witnesses  named  to  appear  at  a  speci- 
fied time,  also  such  other  persons  as  he  thinks  proper.  At  the  time 
appointed,  unless  there  is  an  adjournment,  there  shall  be  a  trial  before 
the  court,  either  with  or  without  a  jury. 

If  the  facts  stated  shall  be  found  true,  an  order  shall  be  entered  of 
record,  stating  that  the  person  found  to  be  insane  is  a  fit  subject  for 
treatment  in  the  asylum.  The  order  shall  require  the  medical  witness  to 
make  out  a  detailed  history  of  the  case,  and  also  that  the  clerk  of  the 
court  make  application  to  the  superintendent  of  the  asylum  for  the 
patients  admission.  If  the  patient  is  dangerous  to  be  at  large,  that  fact 
shall  be  set  forth.  The  superintendent,  on  receiving  the  application  and 
a  copy  of  the  order  of  the  court,  shall  immediately  advise  the  clerk 
whether  the  patient  can  be  received,  and,  if  so,  at  what  time.  If  the 
patient  can  be  admitted,  the  clerk  shall  issue  his  warrant  to  the  sheriff' 
or  some  suitable  person,  the  relatives  of  the  insane  person  having  a  pref- 
erence, directing  that  the  insane  person  be  arrested  and  conveyed  to  the 
State  Lunatic  Asylum.  If  there  is  necessity,  he  may  authorize  one  or 
more  assistants.  The  superintendent  shall  acknowledge  on  the  writ  the 
receipt  of  the  patient,  and  the  warrant  shall  be  returned  into  court. 

A  pay  patient  may  become  a  county  patient,  if  the  county  court  so 
order.  In  such  case,  the  clerk  of  the  court  shall  send  to  the  superinten- 
dent a  certificate,  stating  that  the  patient  has  not  estate  sufficient  to 
support  him  in  the  asylum.  A  county  patient  may  become  a  pay  patient 
by  order  of  the  county  court,  and  the  filing  of  the  proper  certificate, 
stating  the  ability  of  the  patient  to  pay. 

31 


482  APPENDIX  —  MISSOURI. 

Whenever  the  superintendent  desires  the  removal  of  a  county  patient 
from  the  asylum,  he  shall  notify  the  clerk  of  the  county  court  of  the 
county  from  which  such  patient  was  sent,  and  the  clerk  shall  have  the 
patient  removed  by  the  sheriff". 

If  any  person,  by  lunacy  or  otherwise,  shall  be  furiously  mad  or 
dangerous,  it  shall  be  the  duty  of  his  guardian,  or  other  person  under 
whose  care  he  may  be,  to  confine  him  in  some  suitable  place  until  the 
next  sitting  of  the  probate  court  for  the  county,  when  such  order  shall  be 
made  by  the  court  for  the  restraint,  support,  and  safe  keeping  of  the 
person,  as  the  circumstances  of  the  case  shall  require. 

If  the  persons  in  charge  of  such  an  insane  patient  fail  to  confine  him, 
or  if  there  is  no  one  in  charge  of  him,  any  judge  of  a  court  of  record, 
or  any  two  justices  of  the  peace,  may  cause  him  to  be  apprehended,  and 
may  employ  some  one  to  confine  him  in  a  suitable  place  until  the  probate 
court  makes  such  further  orders  as  the  case  may  require. 

When  a  person  tried  upon  indictment  for  any  crime  or  misdemeanor 
shall  be  acquitted  on  the  sole  ground  that  he  was  insane  when  the  offence 
was  committed,  the  fact  shall  be  found  by  the  jury  in  their  verdict,  and 
also  whether  the  prisoner  has  recovered  or  not.  If  the  prisoner  has 
recovered,  he  shall  be  discharged.  If  he  has  not  recovered,  and  is  not  a 
poor  person,  and  the  court  is  satisfied  it  would  be  unsafe  to  permit  him 
to  go  at  large,  the  court  shall  order  that  he  be  sent  to  the  asylum.  The 
sheriff"  shall  keep  such  prisoner  in  the  county  jail,  poor-house,  or  other 
safe  custody,  until  such  time  as  he  can  be  received  into  the  asylum,  and 
then  shall  transfer  him  there.  The  costs  and  the  expense  of  maintaining 
such  insane  person  shall  be  taxed  by  the  court  each  term,  and  collected 
out  of  the  prisoner's  estate.  If  the  prisoner  is  a  poor  person,  the  court 
shall  order  him  to  be  kept  in  safe  custody  by  the  sheriff"  until  the  county 
court  shall  cause  him  to  be  removed  to  the  asylum,  as  in  the  case  of 
insane  poor  persons ;  provided,  however,  that  no  further  examination 
into  the  insanity  of  the  prisoner  need  be  made.  By  an  indigent  or  poor 
insane  person  is  meant  one  who  is  worth,  above  his  debts,  and  excluding 
property  exempt  from  execution,  less  than  $300 :  or,  if  he  has  a  family, 
less  than  $1000,  after  deducting  out  also  the  expense  of  supporting  his 
family  for  one  year. 

If  any  convict,  before  the  execution  in  whole  or  in  part  of  the  sentence 
of  the  court,  becomes  insane,  it  shall  be  the  duty  of  the  Governor  to 
inquire  into  the  facts ;  and  he  may  pardon  such  lunatic,  or  commute  the 
execution,  and  may  order  such  lunatic  to  be  conveyed  to  the  asylum,  and 
there  kept  until  restored  to  reason.  If  the  sentence  is  only  suspended 
for  a  time,  it  shall  be  executed  'at  the  expiration  of  the  period,  unless  the 
Governor  direct  otherwise.  If  any  person,  after  indictment  and  before 
trial,  becomes  insane,  the  circuit  or  criminal  court  wherein  such  person 
stands  charged  shall  suspend  proceedings,  and  order  a  jury  to  be  sum- 
moned to  try  the  question  of  the  insanity  of  the  person.  The  judge  shall 
notify  the  prosecuting  attorney  of  the  inquiry,  and  also  the  alleged  insane 
person,  unless  the  court  order  him  to  be  brought  before  it.  If  the  jury 
find  that  the  person  has  become  insane,  the  judge  shall  order  him  to  be 
sent  to  the  lunatic  asylum.  If  he  ever  recovers  his  sanity,  the  proceed- 
ings against  him  shall  go  on  as  if  there  had  been  no  interruption.     If  the 


APPENDIX — MONTANA.  483 

jury  find  that  he  has  not  become  insane,  then  the  trial  shall  go  on  in  the 
same  manner  as  though  no  such  inquiry  had  been  made. 

If,  after  any  convict  is  sentenced  to  the  punishment  of  death,  the 
sheriff  has  cause  to  believe  that  he  has  become  insane,  he  may  summon  a 
jury  of  twelve  men,  and  give  notice  to  the  prosecuting  attorney,  and  have 
the  question  tried.  If  it  is  found  that  such  convict  is  insane,  the  sheriff 
shall  suspend  the  execution  until  he  receives  a  warrant  from  the  Governor 
or  the  court,  directing  him  to  proceed  with  the  execution. 


MONTANA.^    (Territory.) 

There  being  as  yet  no  public  insane  asylum  established,  the  commis- 
sioners of  the  insane  are  authorized  to  make  a  contract  with  some  person 
to  take  charge  of  and  care  for  insane  persons  who  shull  be  delivered  to 
him.  The  Governor  also  may  make  contracts  for  the  care  of  the  indigent 
insane  of  the  Territory,  and  may  pay  the  expense  of  sending  patients  out 
of  the  Territory  to  their  friends  if  he  deem  it  advisable. 

It  is  the  duty  of  the  probate  judge,  or,  in  his  absence  or  inability 
to  act,  of  the  chairman  of  the  board  of  county  commissioners  of  the 
several  counties  (upon  the  application  of  any  person,  under  oath,  stating 
that  any  person,  by  reason  of  insanity,  is  unsafe  to  be  at  large,  or  is  suf- 
fering from  mental  derangement),  to  cause  such  person  to  be  brought 
before  him,  and  also  a  jury  of  three  citizens  of  his  county,  one  of  whom 
shall  be  a  licensed  practising  physician.  A  hearing  shall  be  had  by  the 
jury,  and  an  examination  shall  be  made  of  the  alleged  insane  person.  If 
the  jury,  after  a  careful  examination,  certify  that  the  charge  is  correct, 
and  the  probate  judge  or  commissioner  is  satisfied  that  such  person,  by 
reason  of  insanity,  is  unfit  to  be  at  large,  or  is  incompetent  to  provide  for 
his  own  proper  care  and  support,  and  has  no  property,  ,and  no  near 
kindred  of  sufficient  means  to  provide  for  such  maintenance,  or  if  such 
kindred  neglect  and  refuse  to  care  for  him,  then  the  judge  or  county 
commissioners  shall  make  out  duplicate  warrants,  reciting  the  facts,  and 
give  them  to  the  sheriff",  who  shall  immediately  convey  the  insane  person 
named  and  deliver  him  to  the  contractor  employed  to  care  for  insane 
persons.  The  contractor  shall  acknowledge  the  receipt  .of  the  patient, 
and  the  warrants  shall  be  returned,  one  to  the  judge  or  county  commis- 
sioner issuing  it,  and  the  other  to  the  secretary  of  the  board  of  commis- 
sioners of  the  insane. 

When  it  is  represented  to  the  probate  judge,  upon  verified  petition  of 
any  relative  or  friend,  that  any  person  is  insane  or  mentally  incompetent 
to  manage  his  property,  the  judge  must  cause  a  notice  to  be  given  to  the 

1  Laws  of  Montana,  Eevised  Statutes,  1879,  pp.  259.  260,  337,  338,  348,  448,  449, 
555-559.     Laws  of  Montana,  1883,  pp.  112,  113. 


484  APPENDIX  —  MONTANA. 

supposed  incompetent  person  five  days,  at  least,  before  the  hearing,  and 
such  person,  if  able  to  attend,  must  be  produced  before  him.  If,  after  a 
full  hearing  and  examination,  it  appear  to  the  probate  judge  that  the 
person  in  question  is  incapable  of  taking  care  of  himself,  he  shall  appoint 
a  guardian,  -who  shall  have  the  care  and  custody  of  the  person  of  his 
ward  and  the  management  of  his  estate.  The  question  of  the  patient's 
restoration  to  sanity  may  be  determined  by  petition  to  the  probate  judge, 
who  shall  summon  a  jury  and  have  the  question  tried. 

All  persons  adjudged  insane,  whether  indigent  or  not,  shall  be  cared 
for  by  the  Territory,  if  so  desired,  under  the  contract  made  by  the  Gov- 
ernor of  the  Territory  for  the  care  and  maintenance  of  indigent  insane; 
and  no  person  so  adjudged  insane  shall  be  refused  admission  into  any 
asylum  provided  by  the  Territory,  nor  shall  the  Territory  ask  or  receive 
any  compensation  therefor. 

If  any  defendant  in  a  criminal  case,  upon  whom  the  court  is  about  to 
pass  judgment,  declare  that  he  is  insane,  the  court,  if  it  finds  there  is 
reasonable  cause  for  believing  the  declaration,  may  order  a  jury  to  be 
impanelled,  and  a  trial  had.  If  the  jury  find  that  the  defendant  is 
insane,  the  court  shall  order  him  to  be  placed  in  the  custody  of  the  person 
provided  by  law  for  the  keeping  of  insane  persons ;  if  no  such  person  is 
provided,  then  to  the  custody  of  some  suitable  person.  Whenever  it  shall 
appear  to  the  satisfaction  of  the  court  that  such  person  has  become  sane, 
it  shall  order  him  to  be  produced  for  judgment. 

If  any  defendant,  at  the  time  he  is  arraigned,  declares  that  he  is  in- 
sane, or  there  is  reasonable  cause  for  believing  him  insane,  the  like 
proceedings  shall  be  had  as  in  the  case  of  a  prisoner  about  to  receive 
judgment.  If  the  jury  find  that  the  defendant  is  sane,  the  trial  shall 
proceed ;  but  if  insane,  the  defendant  shall  be  delivered  to  the  custody  of 
the  person  provided  by  law  for  the  keeping  of  the  insane,  or  to  the 
custody  of  some  suitable  person.  If  the  defendant  recover  his  sanity, 
the  trial  shall  proceed. 

If,  after  any  criminal  is  sentenced  to  death,  the  sheriff  has  cause  to 
believe  that  such  criminal  has  become  insane,  he  may  summon  a  jury  of 
twelve  competent  jurors,  with  the  concurrence  of  the  judge  of  the  court 
by  which  the  judgment  was  rendered,  to  inquire  into  such  insanity, 
giving  notice  thereof  to  the  prosecuting  attorney.  If  it  is  found  by  the 
jury  that  such  criminal  is  insane,  the  sheriff  shall  suspend  the  execution 
of  the  sentence  until  he  receives  a  warrant  from  the  Governor,  or  from 
the  supreme  or  district  court,  directing  the  execution  of  the  criminal. 
The  Governor,  as  soon  as  he  is  convinced  that  the  criminal  has  recovered 
his  sanity,  may  appoint  a  time  for  the  execution,  or  may,  in  his  discre- 
tion, commute  the  punishment  to  imprisonment  for  life. 

Whenever  it  appears  that  a  territorial  convict  is  insane,  the  warden,  or 
other  officer  in  charge  of  the  penitentiary  or  prison,  shall  certify  the  fact 
to  the  probate  judge  of  the  county  in  which  the  prison  or  penitentiary 
is.  The  judge  shall  cause  the  convict  to  be  brought  before  him,  and  at 
the  same  time  and  place  a  jury  of  three  citizens  of  his  county,  one  of 
whom  shall  be  a  licensed  physician.  If  the  jury,  after  a  careful  exami- 
nation, certify  that  the  charge  is  correct,  the  judge  shall  have  such  insane 
person  delivered  over  to  the  contractor  for  the  custody,  maintenance,  and 


APPENDIX  —  NEBRASKA.  485 

treatment  of  insane  persons.  If,  before  the  expiration  of  said  convict's 
sentence,  it  appears  to  the  contractor  that  he  is  restored  to  reason,  he 
shall  notify  the  sheriff,  and  such  convict  shall  be  confined  in  the  prison 
or  penitentiary  for  the  remainder  of  his  term. 


NEBRASKA.^ 


In  each  organized  county  there  shall  be  a  board  of  commissioners  of 
insanity  of  three  members,  who  may  subpoena  witnesses,  administer  oaths, 
etc.  The  clerk  of  the  district  court  shall  be  ex  officio  clerk  of  the  board. 
The  other  two  members  shall  be  appointed  by  the  judge  of  the  district 
court,  and  one  of  them  shall  be  a  respectable  practising  physician,  and 
the  other  a  respectable  practising  lawyer.  In  case  of  the  temporary 
absence  or  inability  to  act  of  two  of  the  commissioners,  the  judge  of  the 
district  court  may  act  in  the  place  of  one  of  the  commissioners,  or  the 
commissioner  present  may  call  to  his  aid  a  respectable  practising  physi- 
cian or  lawyer.  The  commissioners  shall  have  cognizance  of  all  applica- 
tions for  admission  to  the  hospital,  or  for  the  safe  keeping  otherwise  of 
insane  persons  in  their  respective  counties,  except  in  cases  specially  pro- 
vided for. 

Applications  for  commitment  shall  be  made  in  the  nature  of  an  infor- 
mation alleging  that  the  person  is  believed  by  the  informant  to  be  insane 
and  a  fit  subject  for  treatment  in  the  hospital,  and  must  state  that  such 
person  is  found  in  the  county,  and  give  what  is  known  in  regard  to  his 
settlement.  The  commissioners  shall  at  once  investigate  the  case,  and 
may  require  the  alleged  insane  person  to  be  brought  before  them,  and 
kept  in  suitable  custody  until  their  investigation  is  concluded ;  but  they 
may  dispense  with  this,  if  they  think  it  will  be  injurious  to  such  person, 
or  for  any  reason  deem  it  unnecessary.  They  shall  hear  the  testimony 
offered  for  and  against  the  application,  and  in  each  case  shall  appoint 
some  regular  practising  physician  of  the  county,  who  may,  or  may  not, 
be  of  their  own  number,  to  see  the  alleged  insane  person,  and  make  a 
personal  examination.  This  physician  shall  make  a  certificate,  stating 
whether  or  not  he  finds  the  person  insane,  and,  in  connection  with  his 
examination,  he  shall  endeavor  to  obtain  from  the  relatives  of  the  insane 
person,  or  from  others,  correct  answers  to  certain  prescribed  questions 
touching  the  history  and  condition  of  the  patient.  The  questions  and 
answers  shall  be  attached  to  his  certificate.  On  the  return  of  this  certi- 
ficate, the  commissioners  shall  find  whether  the  person  alleged  to  be 
insane  is  insane,  and  whether  he  is  a  fit  subject  for  treatment  in  the 
hospital.  They  shall  also  state  what  is  ascertained  about  his  settlement. 
If  the  person  is  found  insane,  they  shall  issue  a  warrant  authorizing  the 

1  Compiled  Statutes  of  Nebraska,  Guy  A.  Brown,  1881,  pp.  292,  300-309,  732,  747. 


486  APPENDIX  —  NEBRASKA. 

superintendent  of  the  hospital  to  receive  and  keep  such  person  as  a 
patient.  The  sheriff  shall  then  deliver  the  patient,  with  the  physician's 
certificate  and  the  order  of  the  court,  to  the  superintendent  of  the  hos- 
pital. If  the  sheriff  is  not  at  hand,  the  commissioners  may  appoint  some 
other  suitable  person  to  execute  the  Avarrant ;  but  no  female  shall  be  taken 
to  the  hospital  without  the  attendance  of  some  other  female  or  some  rela- 
tive. Any  relative  or  friend  of  the  patient,  who  is  a  suitable  person, 
shall  have  the  privilege,  if  he  so  request,  of  executing  the  warrant,  but 
shall  receive  no  fees  for  so  doing.  The  warrant  endorsed  by  the  super- 
intendent, acknowledging  the  receipt  of  the  patient,  shall  be  returned  to 
the  clerk  of  the  commissioners. 

If  a  patient  has  a  legal  settlement  in  any  county,  his  expenses  shall  be 
paid  by  that  county.  If  he  has  no  legal  settlement,  his  expenses  shall 
be  paid  by  the  State.  All  patients  shall  be  on  an  equal  footing  in  the 
hospital,  except  that  if  the  relatives  or  immediate  friends  of  any  patient 
shall  desire  it,  and  shall  pay  the  expense  thereof,  a  patient  may  have 
special  care.  The  relatives  or  friends  of  any  patient  in  the  hospital  shall 
have  the  privilege  of  paying  any  portion,  or  the  whole,  of  the  expenses 
of  such  patient. 

If  the  hospital  is  full,  or  if  for  any  reason  the  patient  cannot  be 
received  and  it  is  not  safe  that  he  be  allowed  to  go  at  liberty,  the  com- 
missioners shall  require  that  such  patient  be  suitably  provided  for 
otherwise,  until  such  admission  can  be  had.  Such  patients  shall  be  cared 
for  either  as  public  or  as  private  patients.  Those  shall  be  treated  as 
private  patients  whose  relations  or  friends  will  agree  to  provide  for  them 
without  public  charge.  The  commissioners  shall  appoint  some  suitable 
person  as  special  custodian  to  restrain  and  care  for  such  patients  in  such 
way  as  best  to  secure  their  comfort  and  safety  and  the  safety  of  others. 

In  the  case  of  public  patients,  the  commissioners  shall  require  that  they 
be  restrained  and  cared  for  by  the  commissioners  of  the  county  or  over- 
seers of  the  poor  at  the  expense  of  the  county.  If  there  is  no  poor-house 
for  the  reception  of  such  patients,  or  if  no  more  suitable  place  can  be  found, 
they  may  be  confined  in  the  jail  of  the  county  in  charge  of  the  sheriff. 

Where  persons  are  alleged  to  be  insane,  but  it  is  not  desired  to  send 
them  to  the  hospital,  the  commissioners  of  the  insane,  on  application, 
may  make  examination,  and,  on  proof  of  their  insanity  and  need  of 
care,  may  make  provision  for  their  restraint  and  care  within  the  county, 
either  as  public  or  private  patients. 

•  Insane  persons  who  have  been  under  care  outside  of  the  hospital  by 
authority  of  the  commissioners  of  the  insane  of  any  county  may,  on 
application,  be  transferred  by  the  commissioners  to  the  hospital,  when- 
ever they  can  be  admitted  thereto.  If  the  admission  is  within  six  months 
after  the  inquest  already  had,  another  inquest  shall  not  be  necessary, 
unless  the  commissioners  deem  it  advisable. 

If  it  becomes  necessary,  for  want  of  room  in  the  hospital,  to  discrimi- 
nate in  the  general  reception  of  patients,  a  selection  shall  be  made  as  fol- 
lows :  (1)  Recent  cases  (of  less  than  one  year's  duration).  (2)  Chronic 
cases  (of  more  than  a  year's  standing,  but  with  favorable  prospects  of 
recovery).  (3)  Cases  which  have  been  longest  on  file.  (4)  The  indigent 
have  a  preference,  other  things  being  equal. 


APPENDIX  —  NEBRASKA.  487 

Any  patient  who  is  cured  shall  be  immediately  discharged  by  the 
superintendent.  Upon  such  discharge,  the  patient,  if  not  otherwise 
supplied,  shall  be  provided  by  the  superintendent  with  suitable  clothing 
and  a  sum  of  money  not  exceeding  $20. 

If  a  patient  proves  incurable  and  is  not  dangerous  to  be  at  large,  his 
relatives,  with  the  consent  of  the  board  of  trustees,  may  remove  and  take 
charge  of  him. 

If  a  patient  in  the  hospital  is  not  cured  and  is  dangerous  to  be  at  large, 
the  commissioners  of  insanity  of  the  county  where  he  belongs,  on  making 
provision  for  the  care  of  such  patient  within  the  county,  may  authorize 
his  discharge,  if  the  relatives  or  immediate  friends  request  it. 

The  board  of  trustees,  or,  in  the  interim  between  the  meetings  of  the 
board,  the  superintendent  with  two  trustees,  may  order  the  discharge  or 
removal  of  incurable  and  harmless  patients,  whenever  it  is  necessary  to 
make  room  for  recent  cases.  If  patients  so  discharged  need  further  care, 
the  commissioners  of  insanity  shall  be  notified,  and  shall  at  once  provide 
for  their  care  in  the  county. 

If  it  is  alleged  that  a  person  confined  as  a  patient  in  the  hospital  is  not 
insane,  and  is  unlawfully  detained,  a  judge  of  the  district  court  of  the 
county  in  which  the  hospital  is  situated,  or  of  the  county  Avhere  the 
person  detained  belongs,  shall  appoint  a  commission  of  not  more  than 
three  persons,  one  of  them  a  physician,  and,  if  two  or  more  are  appointed, 
one  a  lawyer,  and  they  shall  inquire  into  the  merits  of  the  case.  They 
shall  have  an  interview  with  the  patient  in  such  manner  as  they  deem 
most  desirable,  shall  talk  with  the  officers,  and  examine  the  records  of  the 
hospital.  They  shall  then  make  a  report  to  the  judge,  and  shall  accompany 
their  report  with  a  statement  of  the  case  signed  by  the  superintendent. 
If  the  judge  shall  find  the  person  not  insane,  he  shall  order  his  discharge. 
Such  a  commission  shall  not  be  repeated  ottener  than  once  in  six  months, 
in  the  case  of  any  one  patient,  nor  shall  it  be  appointed  within  six 
months  of  the  patient's  commitment. 

The  provisions  in  regard  to  the  support  of  the  insane  at  public  charge 
are  not  construed  to  release  the  estates  of  such  insane  persons,  nor  their 
relatives,  from  liability  for  their  support,  but  the  board  of  county  commis- 
sioners may  release  the  relatives  from  a  portion,  or  even  the  whole  of  the 
burden,  if  they  think  it  reasonable  and  just  to  do  so. 

No  idiots  shall  be  received  or  kept  in  the  hospital,  and  any  such  there 
shall  be  sent  to  the  counties  where  they  belong. 

If  it  is  shown  to  the  satisfaction  of  the  commissioners  of  insanity  of 
any  county  that  a  person  kept  as  a  patient  within  the  county  is  no  longer 
in  need  of  care,  they  shall  at  once  order  his  discharge. 

Insane  persons  from  other  States  and  Territories  may  be  received  on 
the  same  footing,  and  on  the  same  conditions  as  private  pay  patients. 

A  person  who  becomes  lunatic  or  insane  after  the  commission  of  a  crime 
or  misdemeanor,  ought  not  to  be  tried  for  the  offence  during  the  continuance 
of  the  lunacy  or  insanity.  If,  after  verdict  of  guilty  and  before  judg- 
ment pronounced,  such  person  become  lunatic  or  insane,  no  judgment 
shall  be  given  while  such  lunacy  or  insanity  shall  continue.  If,  after 
judgment  and  before  execution"  of  the  sentence,  such  person  shall  become 
lunatic  or  insane,  then,  in  case  the  punishment  be  capital,  the  execution 


488  APPENDIX  —  NEVADA. 

thereof  shall  be  stayed  until  the  recovery  of  said  person.  In  all  such 
cases  it  shall  be  the  duty  of  the  court  to  impanel  a  jury  to  try  the  ques- 
tion whether  the  accused  be,  at  the  time  of  impanelling,  insane  or  not. 

In  the  case  of  convicts,  sentenced  to  death,  who  appear  to  be  insane,  a 
judge  of  the  district  court  shall  summon  a  jury  of  twelve  men  to  inquire 
into  such  insanity,  and  shall  giVe  notice  of  the  time  of  trial  to  the  district 
attorney.  If  the  finding  shall  be  that  the  convict  is  insane,  the  judge 
shall  suspend  the  execution,  and  notice  shall  be  sent  to  the  Governor. 
When  the  Governor  becomes  satisfied  that  the  convict  has  recovered  his 
sanity,  he  may  appoint  a  time  for  the  execution. 

No  person  alleged  to  be  insane  shall  be  restrained  of  his  liberty,  other- 
wise than  as  provided  by  law,  except  for  the  safety  of  persons  or  property 
until  the  proper  authority  can  be  obtained ;  and  any  one  abusing  or 
treating  an  insane  person  with  wanton  cruelty  or  severity,  shall  be  guilty 
of  a  misdemeanor,  and  liable  to  an  action  for  damages. 


NEVADA.' 


The  judge  of  the  district  court  in  each  judicial  district,  upon  the 
application  of  any  person  under  oath,  setting  forth  that  any  person,  by 
reason  of  insanity,  is  unsafe  to  be  at  large,  or  is  suffering  under  mental 
derangement,  shall  cause  the  said  person  to  be  brought  before  him  at  a 
time  appointed,  and  shall  also  cause  to  appear,  at  the  same  time,  one  or 
more  licensed  practising  physicians,  who  shall  examine  the  person  alleged 
to  be  insane.  If  the  physician,  after  a  careful  examination,  shall  certify 
upon  oath  that  the  charge  is  correct,  and  if  the  judge  is  satisfied  that  the 
person,  by  reason  of  his  insanity,  is  unfit  to  be  at  large,  and  is  incom- 
petent to  provide  for  his  own  care  and  support,  and  has  no  property 
applicable  to  the  purpose,  and  has  no  near  kindred  within  the  State  of 
sufficient  means  or  ability  to  care  properly  for  him  and  his  support,  he 
shall  cause  such  indigent  insane  person  to  be  conveyed  to  the  insane 
asylum  of  the  State,  and  placed  in  charge  of  the  superintendent. 

Paying  patients,  whose  friends  or  property  can  pay  their  expenses, 
shall  pay  according  to  the  terms  directed  by  the  board  of  commissioners; 
but  the  insane  poor  shall  in  all  respects  receive  the  same  medical  care  and 
treatment  from  the  institution,  and  no  record  of  debt  shall  be  made  against 
them. 

When  an  indictment  is  called  for  trial,  or,  upon  conviction,  the  defen- 
dant is  brought  up  for  judgment,  if  a  doubt  shall  arise  as  to  his  sanity, 
the  court  shall  order  the  question  to  be  submitted  either  to  the  regular 
•  jury,  or  to  a  jury  specially  called  to  inquire  into  the  fact.     The  trial  of 

1  Compiled  Laws  of  Nevada,  1873,  Vol.  I.  pp.  206,  525,  526,  539,  540;  Vol.  II. 
pp.  383,  384.    Statutes  of  Nevada,  1879.  p.  140;  1881,  pp.  59-63;  1883,  pp.  102,  103. 


APPENDIX  —  NEW    HAMPSHIRE.  489 

the  indictment  shall  be  suspended  until  the  question  of  sanity  is  deter- 
mined. 

The  mode  of  proceedings  at  the  trial  is  prescribed.  If  the  jury  find 
that  the  defendant  is  sane,  the  trial  of  the  indictment  shall  proceed,  or 
judgment  be  pronounced,  as  the  case  may  be.  If  he  is  found  insane,  the 
trial  or  judgment  shall  be  suspended  until  he  becomes  sane,  and  the 
court,  if  it  deem  the  prisoner's  discharge  dangerous  to  the  public,  may 
order  that  he  be  committed  to  the  care  and  custody  of  some  proper  per- 
son, and  that  upon  his  becoming  sane  he  be  redelivered  to  the  sheriff, 
who  shall  place  him  in  proper  custody  until  he  be  brought  to  trial  or 
judgment,  as  the  case  may  be,  or  be  legally  discharged. 

If,  after  the  judgment  of  death,  there  be  good  reason  to  suppose  that 
the  defendant  has  become  insane,  the  sheriff,  with  the  concurrence  of  the 
judge  Avho  rendered  judgment,  may  summon  a  jury  of  twelve  men  to 
inquire  into  the  supposed  insanity.  The  district  attorney  shall  attend 
the  inquisition.  If  it  be  found  that  the  defendant  is  insane,  the  sheriff 
shall  suspend  the  execution  of  the  judgment  until  he  receives  a  warrant 
from  the  Governor,  who,  when  the  defendant  recovers  his  sanity,  may  fix 
a  day  for  the  execution. 

Whenever  a  convict,  while  undergoing  imprisonment  in  the  Nevada 
State  Prison,  shall  become  insane,  and  be  so  adjudged  by  a  commission 
of  lunacy  appointed  by  the  court,  as  in  other  cases  of  insanity,  it  shall 
be  the  duty  of  the  warden  to  deliver  such  convict  to  the  superintendent 
of  the  State  Insane  Asylum  for  detention  and  treatment. 

If  such  convict  be  restored  to  sanity  before  the  expiration  of  his  sen- 
tence, the  superintendent  shall  deliver  him  to  the  warden  of  the  prison, 
to  be  retained  therein  for  the  unexpired  term  of  his  sentence,  unless  said 
convict  shall  be  released  by  order  of  the  board  of  pardons. 


NEW  HAMPSHIRE.' 

If  any  insane  person  is  in  such  condition  as  to  render  it  dangerous 
that  he  should  be  at  large,  the  judge  of  probate,  upon  petition  of  any 
person,  and  such  notice  to  the  selectmen  of  the  town  in  which  such  insane 
person  is,  or  to  his  guardian,  or  to  any  other  person  as  he  may  order — 
all  which  may  be  done  as  well  in  vacation  as  in  term  time — may  commit 
such  insane  person  to  the  asylum. 

Any  insane  pauper  supported  by  any  town  may  be  committed  to  the 
asylum  by  order  of  the  overseers  of  the  poor,  and  there  supported  at  the 
expense  of  the  person,  town,  or  county  chargeable  with  his  support.  If 
the  overseers  neglect  to  make  such  order  in  relation  to  any  insane  county 
pauper,  the  supreme  court,  or  any  two  judges  thereof  in  vacation,  may 

1  General  Laws  of  New  Hampshire,  1878,  pp.  60-63,  595-597.  New  Hampshire 
Laws,  1879,  p.  389 ;  1881,  p.  530. 


490  APPENDIX  —  NEW    HAMPSHIRE. 

order  such  pauper  to  be  committed  to  the  asylum  and  there  supported  at 
the  expense  of  the  county. 

The  parent,  guardian,  or  friends  of  any  insane  person  may  cause  him 
to  be  committed  to  the  asylum,  with  the  consent  of  the  trustees,  and  there 
supported  on  such  terms  as  they  may  agree  upon.  No  person  shall  be 
committed  to  the  Asylum  for  the  Insane,  except  by  the  order  of  the  court 
or  the  judge  of  probate,  without  the  certificate  of  two  reputable  physicians 
that  such  person  is  insane,  given  after  a  personal  examination  within  a 
week  of  the  committal ;  and  such  certificate  shall  be  accompanied  by  a 
certificate  from  the  judge  of  the  supreme  court,  or  court  of  probate,  or 
mayor,  or  chairman  of  the  selectmen,  testifying  to  the  genuineness  of  the 
signatures  and  the  respectability  of  the  signers. 

Any  insane  person  committed  to  the  asylum  by  his  parent,  guardian, 
or  friends,  who  has  no  means  of  support,  and  no  relatives  of  sufficient 
ability  chargeable  therewith,  and  no  settlement  in  any  town,  and  who  is 
unsafe  to  be  at  large,  shall  be  supported  by  the  county  from  which  he 
was  committed. 

If  any  insane  person  is  confined  in  any  jail,  the  supreme  court  may 
order  him  to  be  committed  to  the  asylum,  if  they  think  it  expedient. 

Any  insane  person  committed  to  the  asylum  by  order  of  the  supreme 
court,  such  person  having  been  charged  with  an  oflfence  the  punishment 
whereof,  as  prescribed  by  law,  is  death  or  confinement  in  the  State  Prison, 
shall  be  supported  at  the  expense  of  the  State. 

Any  person  committed  to  the  asylum  may  be  discharged  by  any  three 
of  the  trustees,  or  by  any  justice  of  the  supreme  court,  whenever  the 
cause  of  commitment  ceases,  or  a  further  residence  at  the  asylum  is  not 
necessary. 

But  any  person  so  discharged,  who  was  under  sentence  of  imprison- 
ment, which  has  not  expired,  shall  be  remanded  to  prison. 

Some  of  the  trustees  shall  visit  the  asylum  at  least  twice  a  month,  and 
shall  give  the  patients  an  opportunity  to  see  them  in  private.  If,  in  their 
opinion,  a  further  residence  at  the  asylum  is  not  necessary  for  any  patient, 
it  shall  be  their  duty  to  discharge  him.  Patients  are  to  be  fiirnished  with 
writing  materials,  and  may  send  letters  to  the  board  of  trustees,  which 
shall  be  delivered  without  inspection. 

Whenever  the  grand  jury  shall  omit  to  find  an  indictment  against  any 
person  for  the  reason  of  insanity  or  mental  derangement,  or  any  person 
prosecuted  for  an  offence  shall  be  acquitted  by  the  petit  jury  for  the  same 
reason,  the  court,  if  they  are  of  opinion  that  it  will  be  dangerous  to  the 
people  that  such  person  should  go  at  large,  may  commit  him  to  the 
prison,  or  to  the  Asylum  for  the  Insane,  there  to  remain  until  he  is  dis- 
charged by  due  course  of  law. 

The  Governor  and  Council,  or  the  supreme  court,  may  discharge  any 
such  person  from  prison  or  transfer  any  prisoner  to  the  Asylum  for  the 
Insane,  whenever  they  are  satisfied  that  such  discharge  or  transfer  will 
be  conducive  to  the  health  and  comfort  of  such  person,  and  to  the  welfare 
of  the  public. 

In  case  of  the  sudden  death  of  any  patient  in  the  asylum,  a  coroner's 
inquest  shall  be  held. 


APPENDIX  —  NEW    JERSEY.  491 


NEW  JERSEY. 


No  person  shall  be  committed  to  an  insane  asylum,  except  upon  an 
order  of  some  court  or  judge  authorized  to  send  patients,  without  lodging 
with  the  superintendent  (1)  a  request,  signed  by  the  applicant,  giving 
the  name,  residence,  and  various  other  facts  regarding  the  patient,  and 
(2)  a  certificate,  dated  within  one  month,  signed  by  a  respectable  physi- 
cian, certifying  the  patient's  insanity.  Each  person  signing  the  request 
or  certificate  must  give  his  residence  and  occupation. 

Each  county  shall  be  entitled  to  send  its  just  proportion  of  patients. 
Whenever  any  pauper  in  a  county  entitled  to  send  patients  to  the  asylum 
may  be  insane,  it  shall  be  the  duty  of  the  overseers  of  the  poor  in  the 
township  where  he  resides  to  apply  to  a  judge  of  the  court  of  common 
pleas  of  the  county.  The  judge  shall  call  one  respectable  physician,  and 
make  an  investigation,  and,  if  satisfied  that  the  disease  is  of  such  a  nature 
as  may  be  cured,  he  shall  make  a  provisional  order  that  the  pauper  be 
taken  to  the  asylum,  and  kept  until  restored,  if  this  be  eifected  in  three 
years.  Before  this  order  shall  take  effect,  it  shall  be  submitted,  with  the 
other  papers  in  the  case,  to  the  "chosen  freeholders"  of  the  township 
where  such  lunatic  is  found,  who,  if  they  are  satisfied  that  the  lunatic  has 
a  legal  settlement  in  their  county,  shall  endorse  their  approval  upon  the 
order,  and  it  shall  then  be  executed,  and  the  pauper  taken  to  the  asylum. 
Copies  of  all  the  papers  and  proceedings  shall  be  sent  to  the  superinten- 
dent of  the  asylum.  The  case  shall  also  be  reported  to  the  board  of 
chosen  freeholders,  who  shall  raise  the  money  for  the  pauper's  support  in 
the  asylum. 

When  a  person  who  is  in  indigent  circumstances,  but  not  a  pauper, 
becomes  insane,  application  may  be  made  to  any  judge  of  the  court  of 
common  pleas  of  the  county  where  he  resides,  and  the  judge  shall  call  a 
respectable  physician  and  other  witnesses,  and,  either  with  or  without  the 
verdict  of  a  jury,  in  his  discretion,  shall  decide  the  case  as  to  the  patient's 
insanity  and  indigence. 

If  he  find  the  person  insane,  and  his  estate  insufficient,  he  may  make 
a  certificate  which  will  entitle  the  patient  to  admission  to  the  asylum,  and 
to  support  there,  at  the  expense  of  the  county,  until  he  is  restored  to 
sanity,  if  effected  in  three  years.  If  the  investigation  is  made  without 
summoning  a  jury,  the  certificate  of  the  judge  must  be  approved  by  the 
"freeholders"  of  the  township  in  the  manner  above  stated  in  the  case  of 
an  insane  pauper. 

When  the  expenses  of  an  indigent  patient  in  the  asylum  have  been 
paid  by  his  friends  for  six  months,  if  the  superintendent  shall  certify  that 
he  is  a  fit  patient,  and  likely  to  be  benefited  by  remaining  in  the  institu- 
tion, the  "chosen  freeholders"  of  the  county  of  his  residence,  on  appli- 
cation made,  may  defray  the  expenses  of  his  remaining  a  year,  and  may 

1  Revision  of  the  Laws  of  New  Jersey,  1709-1877,  Vol.  I.  pp.  601-628;  Vol.  II. 
p.  1119.     Laws  of  New  Jersey,  1879,  p.  176;  1880,  pp.  89,  90,  204;  1883,  p.  216. 


492  APPENDIX  —  NEW    JERSEY. 

repeat  the  same  for  two  succeeding  years,  upon  like  application,  and  the 
production  of  a  new  certificate  from  the  superintendent  each  year.  No 
patient  is  to  be  admitted  for  a  less  period  than  six  months,  except  in 
special  cases. 

When  there  are  vacancies  in  the  asylum,  the  managers  may  authorize 
the  superintendent  to  receive  paying  patients  upon  the  certificate  of  in- 
sanity by  a  regular  physician,  sworn  to  before  a  magistrate  and  by 
request  of  a  responsible  person,  who  shall  give  bonds. 

Town  and  county  officers,  sending  a  patient  to  the  asylum,  shall  see 
that  he  is  provided  with  suitable  clothing.  Money  paid  for  the  support 
of  an  insane  person  may  be  collected  from  his  estate  or  from  the  persons 
liable  to  maintain  him. 

The  provisions  above  stated  are  not  to  abridge  the  power  of  the  court 
of  chancery  over  the  person  and  property  of  insane  persons. 

If  the  judge  to  whom  application  is  made  on  behalf  of  an  insane  pauper 
is  satisfied  by  the  examination  that  such  pauper,  though  not  curable,  can 
not  be  provided  for  by  the  overseers  of  the  poor  of  the  township,  or  at 
the  poor-house  of  the  township  or  county,  with  comfort,  and  without 
danger  to  himself  and  others,  he  shall  order  the  pauper  to  be  removed  to 
the  asylum. 

If  the  board  of  chosen  freeholders  of  any  county  desire  and  request 
that  a  patient  be  kept  in  the  hospital  beyond  the  period  of  three  years, 
it  may  be  done,  the  county  continuing  to  pay  the  expenses. 

Any  patients,  except  those  under  a  criminal  charge,  or  liable  to  be 
removed  to  prison,  may  be  discharged  by  the  board  of  managers  upon 
the  superintendent's,  certificate  of  a  complete  recovery;  and  they  may 
send  back  to  the  poor-house  of  the  county  or  township  whence  he  came 
any  person  admitted  as  "dangerous"  who  has  been  two  years  in  the 
asylum,  upon  the  superintendent's  certificate  that  he  is  harmless,  and  will 
probably  continue  so,  and  is  not  likely  to  be  improved  by  further  treat- 
ment. When  the  asylum  is  full,  the  managers  may  order  the  removal  of 
a  patient  upon  the  superintendent's  certificate  that  he  is  manifestly  incur- 
able, and  can  probably  be  rendered  comfortable  at  the  poor-house ;  and 
they  may  also  discharge  and  deliver  any  patient,  except  one  under  a 
criminal  charge,  to  his  relatives  or  friends,  who  will  undertake  with  good 
sureties  for  his  peaceable  behavior,  custody,  and  maintenance,  without 
further  public  charge. 

No  patient  shall  be  discharged  without  suitable  clothing,  and  money 
not  exceeding  f  10, 

If  a  person  is  lunatic,  and  in  need  of  a  guardian,  a  commission  of 
lunacy  shall  issue  out  of  the  court  of  chancery,  and  an  inquest  shall  be 
held.  If  the  lunacy  is  found,  the  chancellor  shall  transmit  a  copy  of  all 
the  proceedings  to  the  orphans'  court,  where  a  suitable  person  shall  be 
appointed  as  guardian,  who  shall  have  the  care  and  safe  keeping  of  the 
lunatic  and  his  property.  No  lunatic  or  idiot  shall  be  arrested  or  held 
in  custody  on  any  civil  process,  and  if  such  a  person  is  arrested,  a  writ 
of  habeas  corpus  may  issue. 

If  any  lunatic  furiously  mad  or  dangerous  is  found  going  at  large,  any 
two  justices  of  the  peace  of  the  county  iivhere  he  is  found  may  direct  the 
overseers  of  the  poor  of  the  city  or  township  to  cause  him  to  be  appre- 


APPENDIX  —  NEW    JERSEY. 

bended,  and  safely  locked  up  and  chained,  if  necessary,  in  some  secure 
place  in  the  city  or  township  where  he  has,  or  had,  his  last  legal  settle- 
ment. If  he  has  no  settlement  that  can  be  ascertained,  he  may  be 
conveyed  to  any  place  provided  in  the  county  for  the  reception  of  maniac 
or  lunatic  persons,  and,  if  there  is  no  such  place,  he  may  be  taken  to  the 
jail,  there  to  be  safely  kept  until  his  place  of  settlement  is  ascertained, 
or,  failing  in  that,  some  order  on  the  subject  is  made  by  the  court  of 
common  pleas. 

The  expenses  shall  be  collected  out  of  the  estate  of  the  lunatic,  or,  if 
he  has  no  estate,  they  shall  be  paid  by  the  township  or  county,  according 
as  he  has  a  settlement  or  not. 

These  provisions  are  not  intended  to  abridge  the  authority  of  the  chan- 
cellor touching  such  lunatic,  nor  to  prevent  any  of  the  friends  or  relations 
of  such  person  taking  him  under  their  own  protection,  so  long  as  they 
can  take  care  of  him. 

It  is  the  duty  of  the  overseers  of  the  poor  of  the  several  townships  in 
each  county  to  make  out  a  list  of  all  the  poor  lunatics  and  idiots  within 
their  limits,  giving  all  the  facts  connected  with  each  case.  If  the  board 
of  chosen  freeholders  of  the  county  think  there  is  reasonable  ground  for 
believing  that  any  of  such  persons  can  be  restored  to  their  right  mind, 
they  shall  have  them  taken  to  the  State  Lunatic  Asylum. 

When  a  person  shall  have  escaped  indictment,  or  have  been  acquitted 
of  a  criminal  charge  or  of  a  misdemeanor  upon  trial,  on  the  ground  of 
insanity,  the  court  shall  carefully  inquire  whether  his  insanity  in  any 
degree  continues,  and,  if  it  does,  shall  order  him  in  safe  custody,  and  to 
be  sent  to  the  asylum. 

If  any  person  in  confinement  under  indictment,  or  under  any  other 
than  civil  process,  shall  appear  to  be  insane,  the  judge  of  the  circuit  court 
of  the  county  where  he  is  confined  shall  make  an  investigation,  call  a 
respectable  physician  and  other  witnesses,  invite  the  prosecutor  of  the 
pleas  to  aid  in  the  examination,  and,  if  he  deem  it  necessary,  call  a  jury. 
If  it  is  proved  that  the  person  is  insane,  the  judge  may  discharge  him 
from  imprisonment,  and  order  his  safe  custody  and  removal  to  the  asylum, 
where  he  shall  remain  until  restored  to  his  right  mind.  Whenever  he 
recovers,  he  shall  be  remanded  to  prison  for  further  criminal  proceedings, 
or  be  discharged. 

A  criminal  lunatic  may  be  discharged  by  order  of  one  of  the.  justices 
of  the  supreme  court  if,  upon  due  investigation,  it  shall  appear  safe,  legal, 
and  right  to  make  such  order. 

If  any  person  confined  in  the  State  Prison  as  a  convict  shall  appear 
to  be  insane,  the  judge  of  the  circuit  court  of  the  county  in  which  the 
prisoner  is  situated,  shall,  upon  information  of  the  fact  from  the  physi- 
cian of  the  prison,  institute  an  inquiry,  call  two  respectable  physicians 
and  other  witnesses,  invite  the  Attorney-General  to  aid  in  the  examina- 
tion, and,  if  he  think  it  necessary,  call  a  jury.  If  it  is  proved  that  the 
prisoner  is  insane,  the  judge  may  order  his  safe  custody  and  removal  to 
the  State  Lunatic  Asylum,  to  remain  at  the  expense  of  the  State  until 
restored  to  his  right  mind ;  and  then,  if  his  term  of  imprisonment  shall 
not  have  expired,  he  shall  be  remanded  to  the  prison,  to  serve  out  the 
unexpired  portion  of  his  term  of  imprisonment. 


494  APPENDIX  —  NEW    MEXICO. 

Insane  persons  may  be  sent  to  county  asylums  existing  or  to  be  estab- 
lished, instead  of  the  State  Asylum,  when  it  is  thought  best. 

The  board  of  managers  are  required  to  keep  notes  of  their  visits  in  a 
bound  book  kept  for  the  purpose,  to  be  inserted  in  their  annual  report  to 
the  Governor. 


NEW  MEXICO.^    (Territory.) 

If  any  person  is  alleged  to  be  a  lunatic  or  habitual  drunkard,  it  shall 
be  lawful  for  any  district  judge  in  the  county  where  the  person  is  or 
resides,  to  issue  a  commission  to  inquire  into  the  lunacy  or  habitual 
drunkenness.  No  such  commission  shall  issue  except  upon  a  petition  in 
writing  of  a  relation  by  blood  or  marriage  of  the  person  therein  named, 
or  of  a  person  interested  in  the  estate.  The  commission  may  issue  to  one 
person  only,  or  to  two  or  more.  The  judge  shall  make  an  order  that 
notice  be  given  to  the  alleged  lunatic  or  habitual  drunkard,  or  to  some  of 
his  near  relatives  or  friends.  The  commissioner  or  commissioners  may 
direct  the  sheriff  to  summon  six  or  twelve  persons  upon  the  inquest,  as  the 
case  may  seem  to  require.  If  the  alleged  lunatic  or  habitual  drunkard  is 
without  property,  to  pay  expenses,  the  judge  in  person  may  hold  said 
commission  during  the  terai  of  the  court,  and  have  an  inquest  impanelled 
from  the  jurors  attending  the  court. 

Every  person  aggrieved  by  any  inquisition  may  traverse  the  same  upon, 
or  after,  its  return,  and  proceed  to  trial  thereon  before  a  jury.  Notwith- 
standing any  traverse  that  may  be  pending,  the  court  may  make  such 
order  as  seems  necessary  for  the  care  and  custody  of  the  person  and  the 
management  of  his  estate. 

If  the  person  is  found  a  lunatic  or  habitual  drunkard,  it  shall  be 
lawful  for  the  court  to  commit  the  custody  and  care  of  the  person  or 
estate,  or  both,  of  such  lunatic  to  such  person  or  persons  as  they  shall 
deem  most  suitable.  This  committee  shall  give  security,  and  shall  have 
the  management  and  control  of  the  person  and  estate  of  the  lunatic.  A 
committee  of  the  person  may  be  appointed  separately  from  the  committee 
of  the  estate. 

No  person  found  by  inquisition  to  be  a  lunatic  or  habitual  drunkard, 
shall  be  arrested  on  civil  process ;  and,  if  arrested,  he  shall  be  discharged 
by  the  court. 

If  in  any  civil  action  any  person  arrested  shall  appear  to  be  of  unsound 
mind,  the  jailer  or  keeper  shall  give  notice  of  the  fact  to  two  justices  of 
the  peace,  who  shall,  within  five  days,  attend  at  the  prison  and  make  an 
examination,  and,  if  they  find  the  person  to  be  a  lunatic,  shall  certify  the 
same  to  the  clerk  of  the  district  court.     The  court,  or  a  judge  thereof  in 

»  General  Laws  of  New  Mexico,  L.  B.  Prince,  1880,  pp.  380-389. 


APPENDIX  —  NEW    YORK.  496 

vacation,  shall  appoint  a  day  for  a  hearing,  and  publish  notice,  and 
inform  the  creditor  a  week  at  least  before  the  hearing,  that  application 
has  been  made  for  the  discharge  of  the  prisoner.  If  the  court  or  judge, 
on  the  hearing,  find  the  prisoner  of  unsound  mind,  an  order  shall  be 
made  for  his  discharge,  provided  that,  if  it  appears  that  the  person  is  not 
fit  to  be  set  at  large,  the  court  or  judge  shall  make  an  order  that  he  be 
detained  in  custody,  or  delivered  to  his  kindred  or  friends,  who  shall 
be  responsible  for  his  safe  keeping,  and  who  shall  restrain  him  from  the 
commission  of  any  offence. 

Whenever  it  shall  appear,  upon  the  trial  of  any  person  charged  with  a 
crime  or  misdemeanor,  that  such  person  was  insane  at  the  time  of  the 
commission  of  the  same,  and  he  shall  be  acquitted  by  the  jury  on  that 
ground,  the  court  shall  have  power  to  order  such  person  to  be  kept  in 
strict  custody,  in  such  place  and  in  such  manner  as  to  the  court  seems  fit, 
so  long  as  such  person  continues  to  be  of  unsound  mind. 

The  same  proceedings  shall  be  had  if  any  person  indicted  for  an  offence 
shall,  upon  arraignment,  be  found  to  be  a  lunatic  by  a  jury  impanelled 
for  the  purpose  ;*  or  if,  upon  the  trial  of  any  person  indicted,  he  appears 
to  the  jury  to  be  then  a  lunatic,  the  court  shall  have  him  put  in  the  care 
and  custody  of  some  suitable  person.  If  a  person  found  by  inquisition 
to  be  a  lunatic  or  habitual  drunkard  has  not,  and  if  his  friends  have  not, 
money  for  his  support,  he  shall  be  kept  at  the  expense  of  the  county. 


NEW  YORK.' 


No  person  shall  be  committed  to,  or  confined  as  a  patient  in,  any 
asylum  or  institution,  public  or  private,  except  upon  the  certificate  of 
two  physicians  under  oath  setting  forth  the  insanity.  The  physicians 
must  be  of  reputable  character,  graduates  of  some  incorporated  medical 
college,  permanent  residents  of  the  State,  and  have  been  in  practice  three 
years.  No  certificate  shall  be  made  except  after  a  personal  examination, 
and  in  a  form  prescribed  by  the  lunacy  commissioner.  It  must  be  in  the 
prescribed  form  and  bear  date  not  more  than  ten  days  prior  to  the  com- 
mitment. The  physicians  must  not  be  in  any  way  connected  with  the 
asylum  to  which  the  insane  person  is  committed. 

The  patient  shall  not  be  kept  in  the  asylum  more  than  five  days  unless 
before  or  within  that  time  the  certificate  is  approved  by  a  judge  or  justice 
of  a  court  of  record  of  the  county  or  district  in  which  the  alleged  lunatic 
resides,  and  the  judge  or  justice  before  approving  the  certificate  may  in- 

1  Kevised  Statutes  of  New  York,  Banks  &  Brothers,  7th  ed.  Vol.  III.  pp.  1887, 
1888,  1890,  1899-1933,  2568,  2590,  2649,  2653;  Vol.  IV.,  The  Code  of  Civil  Pro- 
cedure, pp.  318,  464-468;  Code  of  Criminal  Procedure,  pp.  12,  69,  88,  93,  96,  97, 
126,  127,  175;  Penal  Code,  pp.  5,  47,  79,  93.  Laws  of  New  York,  1882,  Vol.  2.  pp. 
109,  500  ;  1883,  p.  199. 


496  APPENDIX  —  NEW    YORK. 

stitute  inquiry,  and,  in  his  discretion,  call  a  jury  to  determine  the  question 
of  lunacy.  There  must  be  a  certificate  from  some  judge  of  a  court  of 
record,  stating  that  the  physicians  have  the  requisite  qualifications. 

The  superintendent  of  any  institution,  public  or  private,  shall,  within 
three  days  of  the  commitment  of  any  insane  person,  make  a  descriptive 
record  of  his  case  in  a  book  especially  provided  for  that  purpose,  and 
keep  a  record  of  his  condition  and  treatment,  from  time  to  time,  including 
the  forms  of  restraint  used.  He  shall  also  record  the  circumstances  of 
the  discharge  or  death  of  all  patients. 

If  a  pauper  becomes  lunatic,  the  county  superintendents  of  the  poor  of 
the  county  or  town  where  he  is  chargeable  may  send  him  to  any  State 
lunatic  asylum  by  an  order  under  their  hands. 

In  case  the  committee  or  guardian  of  any  lunatic,  or  his  relatives, 
neglect  to  confine  or  maintain  him,  or  are  not  of  sufficient  ability  to  do 
so,  the  overseers  of  the  poor  or  constable  of  the  city  or  town  where  any 
such  lunatic  shall  be  found,  shall  report  the  same  forthwith  to  the  super- 
intendent of  the  poor,  who  shall  apply  to  the  county  judge,  special  county 
judge,  or  surrogate,  who,  being  satisfied  that  it  is  dangerous  for  such 
lunatic  to  go  at  large,  shall  order  him  to  be  apprehended  and  properly 
confined,  and  within  ten  days  taken  to  some  State  lunatic  asylum,  or  to 
such  other  asylum  as  may  be  approved  by  a  standing  order  of  the  super- 
visor of  the  county. 

If  any  person,  not  a  pauper  but  in  indigent  circumstances,  becomes 
insane,  application  may  bo  made  to  any  county  judge,  special  county 
judge,  judge  of  a  superior  court  or  common  pleas  of  the  county  where  he 
resides,  and  the  judge  shall  investigate  the  facts  in  the  case,  both  as  to 
indigence  and  as  to  insanity.  If  the  judge  finds  that  there  is  reasonable 
cause,  he  shall  fix  a  time  and  place  for  a  hearing,  and  give  notice  to  one 
of  the  superintendents  of  the  poor  of  the  county  chargeable  with  the  ex- 
pense of  supporting  such  person  in  the  asylum,  and  shall  then  proceed  to 
ascertain  when  such  person  became  insane.  The  judge  may  require  the 
friends  of  the  patient  to  give  security  to  remove  him  from  the  asylum  as 
soon  as  he  shall  recover.  If  such  patient  has  not  recovered  at  the  end 
of  two  years,  the  managers  of  the  asylum  may  cause  him  to  be  returned 
to  the  county  from  which  he  came.  The  judge  shall  file  all  the  papers 
in  the  case,  together  with  his  decision,  with  the  clerk  of  the  county,  and 
report  the  facts  to  the  supervisors,  who  shall  provide  the  money  for  the 
support  of  such  indigent  lunatic. 

If  the  expenses  in  the  asylum  of  an  indigent  insane  patient,  not  a 
pauper,  have  been  paid  by  his  friends  for  six  months,  and  the  superin- 
tendent shall  certify  that  he  is  a  fit  patient  and  likely  to  improve,  the 
supervisors  of  the  county  of  his  residence  are  required,  upon  a  sworn  ap- 
plication, to  defray  his  expenses  for  remaining  another  year.  And  they 
shall  repeat  the  same  for  two  years  more,  upon  like  application,  and  the 
production  of  a  new  certificate  from  the  superintendent.  If  any  lunatic, 
or  friend  on  his  behalf,  is  dissatisfied  with  any  final  decision  of  a  county 
judge,  special  county  judge,  surrogate,  judge  of  the  superior  court  or  court 
of  common  pleas,  of  a  city  or  police  magistrate,  in  committing  to  an 
asylum,  he  may,  within  three  days  after  such  order,  appeal  to  a  justice 
of  the  supreme  court,  who  shall  thereupon  stay  all   proceedings,   and 


APPENDIX — NEW    YORK.  497 

forthwith  call  a  jury  to  decide  upon  the  fact  of  lunacy.  If,  after  a  fair 
investigation,  aided  by  the  testimony  of  at  least  two  respectable  physi- 
cians, the  jury  find  the  person  insane,  the  justice  shall  confirm  the  order 
for  his  being  sent  immediately  to  an  asylum. 

If  any  of  the  judges  above  mentioned  refuse  to  make  an  order  for  the 
confinement  of  a  dangerous  insane  person,  they  shall  state  their  reasons 
in  writing,  so  that  any  person  aggrieved  may  appeal  to  a  justice  of  the 
supreme  court,  who  shall  determine  the  matter  in  a  summary  way,  or 
call  a  jury  at  his  discretion. 

No  person  committed  to  any  prison,  jail,  or  house  of  correction,  as  a 
dangerous  lunatic,  shall  be  kept  there  longer  than  ten  days ;  if,  at  the 
end  of  that  time,  he  continues  to  be  insane,  he  shall  be  sent  forthwith  to 
some  State  lunatic  asylum,  or  some  other  approved  asylum. 

If  a  person  found  to  be  a  lunatic,  or  his  committee,  is  not  possessed  of 
sufficient  property  to  maintain  himself,  his  father,  mother,  or  children, 
if  they  are  of  sufficient  ability,  shall  be  compelled  to  provide  for  and 
maintain  him.  If  such  relatives  have  not  sufficient  means,  then  the 
superintendent  of  the  poor  of  the  county  shall  send  such  pauper  lunatic 
to  a  State  asylum,  or  to  such  private  asylum  as  may  be  approved  by  a 
standing  order  of  the  supervisors. 

Whenever  any  person,  who  is  possessed  of  sufficient  property  to 
maintain  himself,  becomes,  by  lunacy  or  otherwise,  so  far  disordered  in 
his  senses  as  to  be  dangerous,  it  shall  be  the  duty  of  the  committee  of 
his  person  and  estate  to  provide  a  suitable  place  for  his  confinement, 
and  to  confine  and  maintain  him  in  such  manner  as  shall  be  approved  by 
the  proper  legal  authority ;  and  in  every  succeeding  attack  of  lunacy  he 
shall  be  sent,  within  ten  days,  to  some  State  lunatic  asylum,  or  to  such 
public  or  private  asylum  as  may  be  approved  by  a  standing  order  of  the 
supervisors  of  the  county.  The  superintendents  and  overseers  of  the 
poor  are  severally  enjoined  to  see  that  this  provision  is  carried  into  eifect, 
as  well  in  cases  where  the  lunatic  or  his  relatives  are  of  sufficient  ability 
to  defray  the  expenses  as  in  case  of  a  pauper. 

The  overseers  of  the  poor  have  authority  to  compel  the  relatives, 
guardian,  or  committee  of  the  person  and  estate,  as  the  case  may  be,  to 
confine  and  maintain  an  insane  person,  at  their  discretion,  and  to  collect 
the  costs  of  his  confinement. 

No  pauper  who  has  not  resided  in  the  State  for  at  least  one  year  next 
prior  to  the  application  shall  be  committed  to  any  State  insane  asylum. 

Any  soldier  or  sailor,  an  inmate  of  the  New  York  State  Soldiers'  and 
Sailors'  Home,  who  shall  be  found  insane,  may  be  transferred  by  an 
order  of  the  president  and  secretary  of  the  board  of  trustees  and  the 
superintendent  of  the  home  to  any  State  lunatic  asylum,  there  to  remain 
at  the  expense  of  said  Soldiers'  Home  until  discharged. 

The  commissioners  of  the  department  of  public  charities  and  correction 
of  the  city  of  New  York  may,  in  their  discretion,  transfer  any  insane 
person  in  their  custody  or  control  to  any  State  lunatic  asylum,  the  officers 
of  which  will  consent  to  receive  the  same.  The  expense  of  maintenance 
shall  be  paid  by  said  commissioners. 

It  shall  be  the  duty  of  all  captains,  owners,  agents,  and  consignees  of 
all  ships  or  vessels  arriving  at  the  port  of  New  York,  having  as  a  pas- 

32 


498  APFENDIX^NEW    YOKK. 

senger  any  lunatic,  to  keep,  provide,  and  care  for  such  person,  on  board 
such  ship  or  vessel,  until  such  person  shall  have  been  delivered  over  and 
placed  under  the  care  of  the  commissioners  of  emigration. 

If  a  person  is  incompetent  to  manage  himself  or  his  affairs  on  account 
of  lunacy,  application  may  be  made  to  the  court  having  jurisdiction  for 
the  appointment  of  a  committee  of  the  person,  or  of  the  property,  or  of 
both.  The  court,  if  the  case  seems  a  proper  one,  shall  make  an  order, 
either  that  a  commission  issue  for  the  purpose  of  inquiring  into  the  case, 
or  that  the  question  be  submitted  to  a  jury  at  a  term  of  the  court.  If 
the  person  is  found  to  be  incompetent,  the  court  makes  such  order  as 
justice  requires.  The  committee  appointed,  either  of  the  person  or  of 
the  property,  must  give  security  before  entering  upon  his  duties. 

If  any  inmate  of  any  State  almshouse,  when  admitted,  is  insane,  or 
thereafter  becomes  insane,  and  the  accommodations  in  the  almshouse  are 
not  adequate  and  proper  for  his  treatment,  the  secretary  of  the  State 
Board  of  Charities  may  cause  his  removal  to  the  appropriate  State  asylum 
for  the  insane. 

A  competent  physician  shall  be  appointed  by  the  Governor  with  the 
consent  of  the  Senate,  who  shall  be  designated  the  State  commissioner 
in  lunacy.  It  shall  be  his  duty  to  visit  and  examine  all  the  asylums, 
public  and  private,  and  report  annually  to  the  legislature.  If  he  has 
reason  to  believe  that  any  person  is  unlawfully  confined  or  improperly 
treated,  or  that  there  is  any  general  mismanagement,  he  shall  make  an 
investigation ;  and  he  is  empowered  to  summon  witnesses,  administer 
oaths,  and  issue  orders  such  as  the  case  may  require.  He  shall  notify 
the  district  attorney,  who  shall  be  present  at  all  his  investigations  into 
matters  of  general  administration  and  management,  to  examine  witnesses 
in  behalf  of  the  people.  The  commissioner  in  lunacy  shall  exercise  the 
powers  belonging  to  referees  appointed  by  the  supreme  court,  and  he 
may  direct  the  authorities  of  the  asylum,  where  affairs  have  been  investi- 
gated, to  correct  any  rule  or  abuses  as  he  thinks  best. 

It  is  also  the  duty  of  the  lunacy  commissioner  to  grant  licenses  for 
private  asylums ;  and  any  person  establishing  a  private  insane  asylum 
without  such  license  is  guilty  of  a  misdemeanor.  If  his  orders  are  dis- 
obeyed, the  case  shall  be  laid  before  the  supreme  court  and  be  by  it  de- 
cided and  disposed  of. 

A  person  is  not  excused  from  criminal  liability,  as  a  lunatic  or  insane 
person,  except  upon  proof  that  at  the  time  of  committing  the  alleged 
criminal  act  he  was  laboring  under  such  a  defect  of  reason  as  either  not 
to  know  the  nature  and  quality  of  the  act  he  was  doing,  or  not  to  know 
that  the  act  was  wrong. 

If  any  person  in  confinement,  under  indictment  for  the  crime  of  arson, 
murder,  or  attempt  at  murder,  or  highway  robbery,  shall  appear  to  be 
insane,  the  court  of  oyer  and  terminer  in  which  the  indictment  is  pend- 
ing may,  with  the  concurrence  of  the  presiding  judge  of  such  court, 
summarily  inquire  into  the  sanity  of  such  person,  and  may,  for  that 
purpose,  appoint  a  commission  to  inquire  into  the  facts  of  the  case,  and 
report  to  the  court ;  and  if  the  court  find  such  person  insane,  or  not  of 
sufficient  capacity  to  undertake  his  defence,  they  may  remand  him  to  such 
State  lunatic  asylum  as  in  their  judgment  is  meet,  there  to  remain  until 


APPENDIX  —  NEW    YORK.  499 

restored  to  his  right  mind,  when  he  shall  be  returned  to  prison  for  further 
criminal  proceedings,  unless  he  be  otherwise  discharged,  according  to  law. 

If  an  J  person  is  confined  under  conviction  for  an  offence  for  which  the 
punishment  is  death,  the  Governor  may  inquire  into  the  case,  appoint  a 
commission,  and,  if  the  convict  is  found  insane  and  irresponsible,  may  order 
his  removal  to  the  State  Asylum  for  Insane  Criminals,  there  to  remain 
until  restored  to  his  right  mind.  The  medical  superintendent  of  the 
asylum,  whenever  he  thinks  the  convict  is  cured  of  his  insanity,  shall 
report  the  fact  to  the  State  commissioner  in  lunacy  and  to  a  justice  of  the 
supreme  court  of  the  district  where  the  asylum  is  situated.  If,  on  inquiry, 
they  are  satisfied  of  his  recovery,  they  shall  cause  the  convict  to  be  re- 
turned to  the  sheriff",  to  be  dealt  with  according  to  law. 

Any  person  charged  with  arson,  murder,  or  attempt  at  murder,  or 
highway  robbery,  and  confined  in  either  of  the  State  lunatic  asylums  as 
insane,  may,  upon  the  application  of  any  superintendent  of  an  asylum, 
be  brought  before  a  justice  of  the  supreme  court,  who  may  order  his 
removal  to  the  Asylum  for  Insane  Criminals  at  Auburn ;  and  convicts 
confined  in  any  penitentiary,  if  insane,  may  be  removed  there,  to  stay 
until  recovered  or  legally  discharged. 

If  any  person  in  confinement  under  any  other  than  civil  process  appears 
to  be  insane,  the  county  judge  of  the  county  where  he  is  confined  shall 
institute  an  investigation,  call  two  physicians  and  other  witnesses,  invite 
the  district  attorney  to  aid  in  the  examination,  and,  if  he  deem  it  neces- 
sary, call  a  jury.  If  the  person  is  found  to  be  insane,  the  judge  may 
order  his  removal  to  a  State  asylum,  to  remain  until  restored.  Whenever 
he  recovers,  he  may  be  remanded  to  prison  for  further  criminal  proceed- 
ings, or,  if  the  period  of  his  imprisonment  has  expired,  he  may  be 
discharged.  The  like  proceedings  may  be  had  in  case  of  an  insane 
person  imprisoned  on  civil  process ;  but  notice  shall  be  sent  to  the 
plaintiff"  in  the  case,  or  to  his  attorney. 

The  defence  of  insanity  must  be  pleaded  in  a  criminal  case  at  the  time 
the  prisoner  is  arraigned.  If  a  defendant  is  acquitted  on  the  ground  of 
insanity,  the  court,  if  they  deem  his  discharge  dangerous  to  the  public 
peace  or  safety,  must  order  him  to  be  committed  to  the  State  Lunatic 
Asylum  until  he  becomes  sane. 

When  a  defendant  pleads  insanity,  the  court  may  appoint  a  commission, 
of  not  more  than  three  persons,  to  examine  the  accused,  and  report  to  the 
court  as  to  his  sanity  at  the  time  the  crime  was  perpetrated.  The  com- 
mission must  be  attended  by  the  district  attorney,  and  the  counsel  for  the 
defendant  may  take  part  in  the  proceedings.  If  the  commission  find  the 
defendant  insane,  the  trial  must  be  suspended  until  he  becomes  sane;  and 
the  court,  if  it  deem  his  discharge  dangerous,  must  order  that  he  be  com- 
mitted to  a  State  lunatic  asylum,  to  remain  until  cured.  When  he  becomes 
sane,  he  must  be  taken  from  the  asylum,  and  put  in  proper  custody  until 
he  is  brought  to  trial. 

If  a  defendant  in  confinement  under  indictment  at  any  time,  before  or 
after  conviction,  appears  to  be  insane,  the  court,  unless  the  defendant  is 
under  sentence  of  death,  may  in  a  like  manner  appoint  a  commission  and 
the  like  proceedings  shall  be  had. 

If,  after  a  defendant  has  been  sentenced  to  death,  there  is  reasonable 


500  APPENDIX — N£W    YORK. 

ground  to  believe  he  has  become  insane,  the  sheriff,  with  the  concurrence 
of  a  justice  of  the  supreme  court  or  the  county  judge  of  the  county,  must 
impanel  a  jury  of  twelve  persons  to  examine  the  question  of  the  sanity 
of  the  defendant.  Notice  of  the  trial  must  be  given  to  the  district 
attorney,  and  he  must  attend.  If  it  be  found  by  the  inquisition  that  the 
defendant  is  insane,  the  sheriff  must  suspend  the  execution  until  he  is 
directed  by  the  Governor  to  proceed.  The  Governor  shall  give  directions 
for  the  disposition  and  custody  of  the  defendant,  and,  as  soon  as  he  is 
satisfied  of  his  restoration  to  sanity,  must  direct  his  execution,  pursuant 
to  his  sentence,  unless  the  sentence  is  commuted  or  the  convict  pardoned. 

No  insane  person  confined  in  any  county  poor-house  or  county  asylum 
shall  be  discharged  by  the  keeper,  or  by  the  superintendent  of  the  poor, 
or  by  any  other  county  authority,  without  an  order  from  a  county  judge 
or  judge  of  the  supreme  court,  founded  upon  evidence  that  it  is  safe, 
legal,  and  right  to  make  such  discharge.  In  New  York  and  Kings 
Counties,  however,  it  shall  be  sufiicient  if  there  is  a  certificate  in  writing 
of  the  physician  of  the  asylum  stating  that  the  discharge  is  safe  and  proper. 

It  is  provided,  in  regard  to  the  Utica  Asylum,  that  no  patient  shall  be 
committed  for  a  shorter  period  than  six  months  except  in  special  cases. 
AVhenever  there  are  vacancies,  paying  patients  may  be  committed  under 
special  agreement,  in  conformity  with  the  law  regarding  commitments, 
if  the  cases  are  recent  and  promise  speedy  recovery,  or  when  admission 
is  sought  under  peculiarly  afflicting  circumstances. 

The  managers,  upon  the  superintendent's  certificate  of  complete 
recovery,  may  discharge  any  patient  except  one  under  a  criminal  charge 
liable  to  be  remanded  to  prison.  They  may  discharge  any  patient  com- 
mitted as  "dangerous,"  or  any  patient  sent  by  the  superintendent  or 
overseers  of  the  poor,  or  by  the  judge  of  a  county,  if  the  superintendent 
certifies  that  the  patient  is  harmless  and  will  probably  continue  so,  and  is 
not  likely  to  be  improved  by  further  treatment.  If  the  asylum  is  full, 
they  may  discharge  patients  manifestly  incurable  that  can  probably  be 
rendered  comfortable  in  the  poor-house,  and  give  preference,  in  the 
admitting  of  patients,  to  recent  cases  or  those  of  not  over  one  year's 
duration.  They  may  discharge  and  deliver  any  patient  except  one  under 
criminal  charge,  to  his  relatives  or  friends,  who  will  give  a  bond  approved 
by  the  county  judge  for  the  patient's  peaceable  behavior,  safe  custody, 
and  comfortable  maintenance  without  further  public  charge.  A  criminal 
lunatic  may  be  discharged  by  order  of  one  of  the  justices  of  the  supreme 
court  or  a  circuit  judge,  when  it  appears  safe,  legal,  and  right  to  make 
such  order.  No  patient  shall  be  discharged  without  proper  clothing  and 
money  not  exceeding  $20  to  pay  his  expenses. 

Insane  female  convicts  at  Sing  Sing  may  be  removed  to  the  asylum  for 
insane  criminals  at  Auburn,  to  stay  until  restored  to  reason,  and  then  be 
returned.  Whenever  any  convict  in  this  asylum  for  insane  criminals 
shall  continue  to  be  insane  at  the  expiration  of  the  term  for  which  he  was 
sentenced,  the  board  of  inspectors,  upon  the  superintendent's  certificate 
that  he  is  haimless  and  is  not  likely  to  be  improved  by  further  treatment, 
or  upon  a  certificate  that  he  is  incurable  and  can  be  made  comfortable  in 
the  county  almshouse,  may  cause  such  insane  convict  to  be  removed  to 
the  county  where  he  was  convicted  or  where  he  belongs  and  placed  under 


APPENDIX  —  NORTH    CAROLINA.  501 

the  care  of  the  superintendents  of  the  poor  of  such  county.  Or  they  may 
deliver  such  convict,  on  the  expiration  of  his  sentence,  to  his  friends,  if 
they  will  give  security  for  his  safe  custody  and  comfortable  maintenance 
"without  public  charge.  If  the  insanity  continues  after  the  expiration  of 
the  convict's  sentence,  he  shall  be  kept  in  the  asylum  until  adjudged  a  fit 
subject  to  be  discharged.  If  any  convict  confined  in  said  asylum  as  a 
lunatic  is  restored  to  reason  and  is  ready  to  be  sent  back  to  prison,  he 
shall  be  sent  to  the  Auburn  State  Prison,  even  though  originally  sen- 
tenced to  some  other  prison,  but  any  convict  received  from  a  penitentiary 
shall  be  returned  to  the  same. 

The  chronic  pauper  insane  from  the  poor-houses  of  the  counties  shall 
be  sent  to  the  Willard  Asylum  by  the  county  superintendents  of  the 
poor,  except  from  those  counties  having  asylums  for  the  insane  to  which 
they  are  authorized  to  send  insane  paupers  by  special  legislative  enact- 
ment, or  those  counties  exempted  by  the  State  Board  of  Charities.  And 
all  the  chronic  insane  paupers  who  may  be  discharged  not  recovered  from 
the  State  lunatic  asylums,  and  who  continue  a  public  charge,  shall  be 
sent  to  the  Willard  Asylum  and  paid  for  by  the  counties  from  which  they 
are  sent. 

The  chronic  pauper  insane  from  such  counties,  and  in  such  numbers  as 
may  be  designated  by  the  State  Board  of  Charities,  shall  be  sent  to  the 
Bingham  ton  Asylum.  Any  of  the  patients  who  are  recovered  or  become 
harmless,  may  be  discharged  by  the  trustees  into  the  care  of  their 
friends.  The  trustees  may  also  deliver  any  patient  who  has  not  recovered 
to  his  friends,  on  their  giving  proper  security  for  his  custody  and  main- 
tenance. Harmless  patients  may  also  be  sent  back  from  this  asylum  to 
the  counties  from  which  they  came,  and  placed  in  the  care  of  the  super- 
intendents of  the  poor. 

Town  or  county  officials,  in  committing  insane  persons,  are  required  to 
send  them  well  provided  with  clothing  and  in  a  cleanly  condition. 

Any  person  found  guilty  of  confining  a  lunatic  in  any  other  manner 
or  in  any  other  place  than  is  prescribed  by  law,  is  liable  to  a  fine  not 
exceeding  $250,  or  imprisonment  not  over  one  year,  or  both,  at  the  dis- 
cretion of  the  court. 

The  terms  lunatic  and  insane  include  all  persons  deranged  or  of  unsound 
mind  except  idiots. 


NORTH  CAROLINA.^ 

For  commitment  to  any  insane  asylum,  some  respectable  citizen,  re- 
siding in  the  county  of  the  alleged  insane  person,  shall  file  with  a  justice 
of  the  peace  of  the  county  an  afiidavit,  in  prescribed  form,  stating  that  he 
has  examined  the  alleged  lunatic,  and  believes  him  to  be  insane,  and  a  fit 
subject  for  the  asylum.     The  justice  of  the  peace  shall  have  the  supposed 

'  Laws  of  North  Carolina,  1883,  pp.  237-261.  581,  621. 


502  APPENDIX  —  NORTH  CAROLINA. 

insane  person  brought  before  him,  and  shall  call  to  his  assistance  one  or 
more  justices  of  said  county,  and  they  together  shall  proceed  to  examine 
into  the  condition  of  mind  of  the  alleged  insane  person.  They  shall  take 
the  testimony  of  at  least  one  respectable  physician,  and  such  others  as  they 
may  think  proper.  If  any  two  of  the  justices  decide  that  the  person  is 
insane,  and  no  friend  is  found  who  will  become  bound  with  good  security 
to  restrain  and  take  care  of  him  until  he  recovers,  the  justices  shall  direct 
that  such  insane  person  be  removed  to  the  proper  asylum  as  a  patient. 
The  justices  shall  make  a  full  report  of  their  proceedings  to  the  clerk  of 
the  superior  court  of  their  county. 

Whenever  an  insane  person  shall  be  conveyed  to  any  asylum,  and  the 
superintendent  is  in  doubt  as  to  the  propriety  of  his  commitment,  he  may 
convene  any  thi-ee  of  the  directors,  who  shall  examine  the  matter.  If  a 
majority  of  the  three  so  decide,  the  patient  shall  be  admitted,  but  three 
directors  may  at  any  time  deliver  the  patient  to  any  friend  who  will 
become  bound  with  good  surety  to  restrain  and  take  care  of  him. 

Any  three  of  the  board  of  directoi*s  of  any  asylum,  upon  the  superin- 
tendent certifying  the  facts,  may  discharge  or  remove  any  person  admitted 
as  insane,  when  such  patient  has  become  of  sound  mind,  or  when  he  is 
incurable,  but  not  dangerous ;  or  the  said  directors  may  permit  a  patient 
to  go  to  the  county  of  his  settlement  on  probation  if  the  superintendent 
thinks  it  advisable. 

If  an  indigent  patient  is  discharged  or  removed,  except  as  being  recov- 
ered, it  shall  be  the  duty  of  the  sheriff  to  take  him  to  his  county.  If  an 
indigent  person  is  discharged  recovered,  he  shall  be  furnished  with  money 
to  pay  his  expenses  of  travel  to  the  county  of  his  settlement. 

All  bonds  for  the  safe  keeping  of  insane  persons  shall  be  in  prescribed 
form,  payable  to  the  State  of  North  Carolina,  and  shall  be  in  the  sum  of 
$500. 

Costs  and  expenses  incurred  in  regard  to  a  patient  shall  be  paid  by  the 
county,  unless  the  patient  or  those  liable  for  his  support  have  means  to 
pay. 

If  a  patient  entrusted  to  a  friend  is  not  cared  for  according  to  the  terms 
of  the  bond,  any  two  justices  of  the  peace  of  the  county  may  send  the 
patient  to  the  proper  asylum,  unless  some  other  responsible  and  discreet 
friend  will  undertake  to  take  charge  of  him. 

The  board  of  public  charities  shall  visit  the  asylum  jfrom  time  to  time, 
and  make  reports  to  the  General  Assembly. 

If  a  person  found  to  be  insane  has  ample  means  to  care  for  his  family 
and  himself,  and  is  capable  of  declaring  his  preference  to  be  placed  in 
some  asylum  outside  the  State,  or  if  his  guardian  declares  such  prefer- 
ence, and  two  respectable  physicians  who  have  examined  him,  with  the 
justices  who  made  the  examination,  deem  it  proper,  the  said  justices  and 
physicians  may  recommend  that  he  be  placed  in  the  asylum  so  chosen. 
The  justices  shall  report  the  proceedings  to  the  clerk  of  the  superior  court 
of  the  county.  The  clerk  shall  lay  the  matter  before  the  judge  of  the 
superior  court  of  the  district  where  the  insane  person  resides,  and,  if  he 
approves,  he  shall  so  declare  in  writing,  which  shall  be  recorded  by  the 
clerk.  The  said  judge  shall  appoint  some  friend  of  the  patient  to  remove 
him  to  the  asylum  designated,  and  a  certified  copy  of  the  proceedings 


APPENDIX  —  OHIO.  503 

shall  be  a  sufficient  warrant  to  authorize  such  friend  to  act  in  the  matter 
of  his  removal. 

In  the  commitment  of  patients  to  the  asylums,  priority  shall  be  given 
to  the  indigent ;  but  the  boards  of  directors  may  also  consider  the  cura- 
bility of  patients.  If  there  is  sufficient  room,  paying  patients  may  be 
received.  If  a  person  found  insane  cannot  be  at  once  committed  to  an 
asylum,  and  he  is  dangerous  to  be  at  large,  and  cannot  otherwise  be 
properly  restrained,  he  may  be  temporarily  committed  to  the  county  jail. 
When  a  patient  kept  in  the  county  jail  is  fit  to  be  discharged,  it  shall  be 
the  duty  of  the  board  of  county  commissioners,  on  the  presentment  of  a 
certificate  of  two  respectable  physicians,  and  of  the  chairman  of  their 
board  stating  the  fact,  to  make  an  order  for  his  discharge. 

The  judges  of  the  superior  court,  in  their  respective  districts,  shall 
commit  to  the  proper  asylum,  if  there  be  room  therein,  as  a  patient,  any 
person  who  may  be  confined  in  jail,  on  a  criminal  charge  of  any  kind,  or 
upon  a  peace  warrant,  whenever  the  judge  shall  be  satisfied,  by  the  ver- 
dict of  a  jury  of  inquisition,  that  the  alleged  criminal  act  was  committed 
while  such  person  was  insane,  and  that  such  insanity  continues ;  and  also 
any  person  acquitted  upon  a  criminal  charge  where,  on  the  trial  of  such 
person,  insanity  was  relied  upon  as  a  defence ;  provided,  the  fact  of  in- 
sanity was  found  as  a  distinct  issue  to  exist  at  the  time  of  such  trial,  or 
is  so  found  by  a  jury  of  inquisition,  as  such  judge  may  direct. 


OHIO.^ 

Each  county  is  entitled  to  send  patients  to  the  State  asylums  in  pro- 
portion to  its  population.  No  person  is  entitled  to  admission  unless  he 
has  lived  in  the  State  one  year  next  preceding  the  date  of  his  application 
and  his  insanity  appeared  while  he  resided  in  the  State.  The  medical 
superintendent  of  each  asylum  shall  inform  the  probate  judges  of  the 
different  counties  in  his  district,  each  month,  of  the  number  of  patients 
to  which  each  county  is  entitled,  and  of  the  number  in  the  asylum  from 
each  county.  If  the  quota  is  not  full,  the  probate  judge  may,  at  any 
time,  send  an  acute  case  conformably  to  the  laws.  Patients  may  be 
transferred  from  one  asylum  to  another  upon  the  order  of  the  Governor, 
and  the  recommendation  of  the  medical  superintendents  of  the  asylums 
affected.  Patients  in  the  asylums  shall  be  maintained  at  the  expense  of 
the  State. 

For  the  commitment  of  patients  to  asylums,  some  resident  citizen  of 
the  proper  county  shall  file  with  the  probate  judge  of  the  county  an 
affidavit,  stating  that  he  believes  the  person  in  question  to  be  insane,  or 

1  Revised  Statutes  of  Ohio,  1880.  Second  Edition,  Revised,  Vol.  I.  pp.  204,  329- 
339,  384;  Vol.  II.  pp.  1505-1509,  1688,  1701,  1702,  1720,  1730,  1736,  1831.  Laws 
of  Ohio,  1881,  pp.  02,  102;  1883,  pp.  103,  104,  181,  182. 


604  APPENDIX — OHIO. 

unfit  to  be  at  large,  on  account  of  insanity,  and  giving  the  place  of  his 
legal  settlement.  The  judge  shall  order  the  alleged  insane  person  to  be 
brought  before  him  on  a  day  named,  which  shall  be  not  later  than  five 
days  after  the  filing  of  the  aflidavit.  He  shall  summon  witnesses,  one  of 
whom  shall  be  a  respectable  physician,  and,  if  the  insanity  is  disputed,  he 
shall  summon  such  witnesses  as  the  parties  opposing  desire.  If  the 
alleged  insane  person  is  not  in  a  fit  condition  to  be  brought  into  court, 
the  judge  shall  visit  him  personally,  and  certify  that  he  has  ascertained 
the  condition  of  the  person  by  actual  inspection,  and  the  proceedings 
shall  go  on  in  the  absence  of  such  insane  person.  If  the  judge,  after 
hearing  the  testimony,  is  satisfied  that  the  person  is  insane,  he  shall 
cause  a  certificate  to  be  made  by  the  medical  witness,  which  shall  set  forth 
information  on  twenty-one  prescribed  points  covering  the  history  and  con- 
dition of  the  patient ;  he  shall  then  apply  to  the  superintendent  of  the 
asylum  in  the  proper  district,  transmitting  copies  of  the  physician's  cer- 
tificate and  his  own  finding  in  the  case.  If  the  patient  can  be  received, 
the  superintendent  shall  notify  the  probate  judge,  and  he  shall  issue  his 
warrant  to  the  sheriff,  or  some  suitable  person  or  persons,  to  take  the 
patient  to  the  asylum.  The  relatives  of  the  patient  shall  have  the  right, 
if  they  desire  it,  to  convey  the  patient  to  the  asylum.  The  receipt  of 
the  patient  shall  be  endorsed  on  the  warrant,  which  shall  be  returned  to 
the  probate  judge  and  filed  with  the  papers  in  the  case.  Before  the 
probate  judge  applies  for  the  commitment  of  the  patient,  the  medical 
witness  must  make  a  certificate  that  the  patient  is  free  from  all  infectious 
diseases  and  from  vermin. 

The  relatives  of  any  person  charged  with  insanity,  or  who  is  found  to 
be  insane,  shall  in  all  cases  have  the  right  to  take  charge  of  and  keep 
him ;  and,  in  such  case,  the  probate  judge  who  holds  the  inquest  shall 
deliver  the  insane  person  to  such  relatives.  When  a  patient  is  sent  to  the 
asylum,  the  probate  judge  shall  see  that  he  has  the  proper  amount  of 
clothing. 

If  the  patient  cannot  be  admitted  to  the  asylum,  the  probate  judge  shall 
have  the  sheriff,  or  some  other  suitable  person,  take  charge  of  him,  until 
such  time  as  he  can  be  received,  and,  if  necessary,  the  judge  may  direct 
the  confinement  of  the  patient  in  the  county  infirmary  or  jail,  but  in  a 
room  separate  from  the  criminals.  The  judge  shall  see  that  things 
necessary  are  furnished,  and,  if  there  is  no  physician  regularly  employed 
to  attend  the  jail  or  infirmary,  he  may  employ  one  to  attend  the  lunatic. 

If  an  insane  pei'son  not  entitled  to  admission  to  the  asylum  is  at  large 
and  dangerous,  the  probate  judge  may  order  him  to  be  confined,  and 
provided  for,  either  by  some  suitable  person,  or  in  the  jail  or  infirmary, 
as  above  stated.  When  the  attending  physician  certifies  that  such  person 
is  restored  to  reason,  or  that  it  is  no  longer  necessary  to  confine  him,  or 
if  his  friends  agree  to  take  care  of  him,  the  probate  judge  shall  order  his 
discharge.  Immediately  after  the  removal,  death,  escape,  or  discharge 
of  any  patient,  or  return  of  an  escaped  patient,  the  superintendent 
shall  notify  the  probate  judge  of  his  county ;  and  he  shall  also,  in  case 
of  death,  notify  one  or  more  of  the  relatives  of  the  deceased  patient. 

Incurable  and  harmless  patients  may  be  discharged  by  the  superinten- 
dent and  one  trustee  when  it  is  necessary  to  make  room  for  a  recent  case 


APPENDIX — OHIO.  505 

from  the  same  county.  The  superintendent  shall  notify  the  probate  judge, 
who  shall  by  his  warrant  order  the  removal  of  the  patient  to  the  township 
of  which  he  is  an  inhabitant.  When  a  patient  is  discharged  as  cured,  the 
superintendent  may  furnish  him  with  suitable  clothing  and  money  not 
exceeding  $20. 

If  a  patient  discharged  as  cured  becomes  a  second  time  insane,  the 
facts  shall  be  set  forth  in  an  aflSdavit  by  a  respectable  physician,  and  the 
probate  judge  shall  make  application  to  the  superintendent  of  the  proper 
asylum  for  his  commitment.  The  same  proceedings  shall  then  be  had  as 
in  case  of  a  person  found  insane  upon  inquest  held  for  the  purpose,  as 
above  stated. 

In  the  admission  of  patients,  selection  shall  be  made  as  follows :  (1) 
Recent  cases  (of  less  than  a  year's  duration).  (2)  Chronic  cases  present- 
ing the  most  favorable  prospect  of  recovery.  (3)  Those  for  whom  appli- 
cations have  been  longest  on  file,  other  things  being  equal.  (4)  No 
county  shall  have  more  than  its  due  proportion  of  patients,  unless  there 
is  some  other  county  in  the  district  without  patients  enough  to  fill  its 
quota. 

If  the  friends  of  a  patient  ask  for  his  discharge  from  the  asylum,  the 
superintendent  may  require  a  bond  for  the  safe  keeping  of  such  patient ; 
but  no  patient  charged  with,  or  convicted  of,  homicide,  shall  be  discharged 
without  the  consent  of  both  the  superintendent  and  the  board  of  trustees 
of  such  asylum. 

The  commissioners  of  every  county  in  which  there  now  is,  or  may  here- 
after be  established,  a  county  infirmary,  shall  provide  separate  apartments 
for  the  safe  keeping  and  treatment  of  lunatics  and  idiots  who  have  not 
been,  and  cannot  be,  received  into  either  of  the  lunatic  asylums,  or  who 
have  been  discharged  therefrom.  The  directors  of  the  infirmary  shall 
provide  for  the  safe  keeping,  support,  and  treatment  of  patients  who  are 
a  charge  upon  the  county,  and  for  the  treatment  and  care  of  such  lunatics 
in  their  county  as  may  be  admitted  as  pay  patients,  under  regulations 
made  by  the  directors.  When  rooms  are  provided  in  the  county  infirmary, 
insane  persons  in  the  county  jail  shall  be  transferred  to  such  infirmary. 

The  directors  of  the  Ohio  Penitentiary  shall  provide  a  suitable  depart- 
ment for  the  reception  of  lunatic  or  insane  convicts,  to  accommodate  the 
convicts  that  become  insane  therein. 

If  at  any  time  before  the  indictment  of  a  person  confined  in  jail 
charged  with  an  offence,  notice  in  writing  be  given  by  any  citizen  to  the 
sherifi"  or  jailer  that  such  person  was  insane  or  an  idiot  at  the  time  the 
offence  was  committed,  or  has  since  become  insane,  the  sheriff  or  jailer 
shall  forthwith  notify  the  probate  judge,  clerk,  and  prosecuting  attorney  of 
the  proper  county,  and  an  examining  court  shall  be  held ;  and  if  the  judge 
find  that  such  person  was  an  idiot  when  he  committed  the  offence,  or  was 
then  and  still  is  insane,  or  afterwards  became  and  still  is  insane,  he  shall, 
at  his  discretion,  proceed  as  [in  the  case  of  a  person  found  insane  by 
inquest  held.  When  such  lunatic  is  restored  to  reason,  the  prosecuting 
attorney  shall  have  him  recommitted  to  the  jail  to  answer  the  offence 
charged  against  him.  If  the  prosecuting  attorney  fails  to  do  this,  the 
superintendent  of  the  asylum  or  infirmary  shall  discharge  such  patient. 


506  APPENDIX  —  OHIO. 

When  a  person  is  under  indictment,  or  held  for  trial  or  sentence,  and  it 
is  suggested  to  the  court  that  the  person  is  not  then  sane,  and  the  certifi- 
cate of  a  respectable  physician  to  the  same  effect  is  presented  to  the  court, 
proceedings  shall  be  had  to  try  his  sanity,  and  the  question  may  be  sub- 
mitted to  a  special  jury.  If  the  person  is  found  insane,  the  probate  judge 
shall  be  notified,  and  shall  deal  with  him  as  an  insane  person  found  so  by 
inquest,  and  upon  recovery  he  shall  be  brought  to  trial  or  sentence.  If 
the  patient  is  discharged  into  the  care  of  his  friends,  the  bond  given  for 
his  support  and  safe  keeping  shall  contain  a  condition  that  he  shall,  when 
restored  to  reason,  answer  to  the  offence  charged  in  the  indictment,  or  of 
which  he  has  been  convicted,  at  the  next  term  of  the  court  thereafter. 

When  a  person  tried  upon  an  indictment  is  acquitted  on  the  sole  ground 
that  he  was  insane,  that  fact  shall  be  certified  by  the  clerk  to  the  probate 
judge,  and  the  defendant  shall  not  be  discharged,  but  shall  be  proceeded 
against  as  insane,  and  the  verdict  shall  be  primd  facie  evidence  of  in- 
sanity. 

When  a  convict  in  the  penitentiary  becomes  insane,  the  warden  shall 
give  notice  to  the  physician  for  the  prison  and  the  superintendent  of  the 
Columbus  Asylum  for  the  Insane,  who  shall  examine  the  convict,  and,  if 
they  find  him  insane,  sliall  certify  the  fact  to  the  warden,  who  shall  forth- 
with put  the  insane  convict  in  the  department  prepared  for  that  purpose. 

Such  insane  convicts  shall  be  treated  by  the  physician  and  by  the 
superintendent  of  said  asylum,  and  when  they  are  restored,  or  it  is  safe 
for  them  to  work,  they  shall  again  be  put  at  hard  labor,  according  to  their 
sentence.  If  a  convict  is  insane  at  the  expiration  of  his  term  of  imprison- 
ment, the  probate  judge  of  the  county  from  which  he  was  sent  shall  take 
him  in  charge,  and  order  him  to  be  confined,  or  otherwise  disposed  of 
and  provided  for,  as  directed  by  law. 

If  a  convict,  at  any  time  before  the  full  execution  of  his  sentence,  be 
represented  to  the  Governor  of  the  State  to  be  insane,  the  Governor  shall 
inquire  into  the  facts.  If  he  thinks  it  proper,  he  may  pardon  the  convict, 
or  commute  the  sentence,  or  suspend  its  execution  for  a  definite  time,  or 
from  time  to  time.  He  may  order  the  convict  to  be  confined  in  the 
penitentiary,  or  a  jail,  or  conveyed  to  an  asylum  for  the  insane  for  treat- 
ment. 

If  the  sentence  is  suspended,  and  the  convict  recover  his  reason,  the 
sentence  shall  then  be  fully  executed. 

If  a  convict  sentenced  to  death  appears  to  be  insane,  the  sheriff  shall 
give  notice  to  a  judge  of  the  court  of  common  pleas  of  the  judicial  dis- 
trict, and  shall  summon  a  jury  of  twelve  men.  The  judge,  clerk,  and 
prosecuting  attorney  shall  attend  the  inquiry,  and,  if  it  be  found  that  the 
convict  is  insane,  the  judge  shall  suspend  the  execution.  The  Governor 
shall  be  notified  of  the  finding,  and  may,  as  soon  as  he  is  convinced  that 
the  convict  has  recovered,  issue  a  warrant  directing  his  execution. 


APPENDIX  —  OREGON.  607 


OREGON.' 


The  insane  have  been  kept  under  the  care  of  a  contractor,  the  State 
paying  a  certain  sum  per  week  for  the  board  of  each  patient. 

The  county  judge,  upon  application  of  any  two  householders  in  his 
county  in  Avriting,  under  oath,  setting  forth  that  any  person  by  reason  of 
insanity  is  suftering  from  neglect,  or  is  unsafe  to  be  at  large,  shall  cause 
such  insane  person  to  be  brought  before  him,  and  shall  cause  to  appear,  at 
the  same  time  and  place,  two  or  more  competent  physicians,  and  the 
prosecuting  attorney  of  the  district,  or  his  deputy,  or,  in  the  event  of  his 
absence,  some  practising  attorney  to  represent  the  State.  If  the  physi- 
cians, after  careful  examination,  shall  certify  on  oath  that  the  person  is 
insane  or  idiotic,  and  the  county  judge  shall  find,  on  the  certificate  and 
the  testimony  produced,  that  the  person  is  insane  or  idiotic,  he  shall 
cause  the  insane  person  to  be  conveyed  to,  and  placed  in  charge  of,  the 
party  or  parties  contracting  to  keep  and  care  for  the  insane  and  idiotic 
of  the  State.  An  appeal  may  be  taken  from  the  decision  of  the  county 
judge  in  the  same  manner  as  is  provided  for  appeal  from  the  judgment  of 
county  courts  in  other  cases.  The  appeal  may  be  taken  either  by  the 
householders  making  application,  or  by  some  one  on  behalf  of  the  alleged 
insane  person,  or  by  the  prosecuting  attorney  on  behalf  of  the  State. 

The  judge  shall  make  inquiry,  and,  if  he  finds  that  the  person  found 
insane  has  any  property,  he  shall  appoint  a  guardian  to  take  care  of  the 
same,  and  said  estate  shall  be  applied  to  supporting  the  family  of  the 
insane  person  and  to  paying  the  expenses  of  his  commitment  and  support. 
All  the  proceedings  shall  be  recorded  in  the  county  court,  and,  if  the 
patient  is  adjudged  insane,  a  warrant  shall  be  made  reciting  the  findings 
of  the  judge,  the  causes  of  the  insanity  when  ascertained,  and  the  name, 
age,  nativity,  and  present  residence  of  the  patient.  The  county  judge 
shall  designate  some  proper  person  or  persons  to  take  the  patient  to  the 
asylum.  Paying  patients  shall  pay  according  to  the  terms  made  with 
the  contractors. 

The  Governor  is  required  to  visit  and  examine  the  insane  confined  by 
law  once  every  six  months.  He  shall  also  appoint  a  physician  who  shall 
visit  and  inspect  the  institution  where  they  are  kept  as  often  as  once 
every  month,  and  oftener  if  necessary.  He  shall  see  that  the  terms  of 
the  contract  made  with  the  State  are  fully  carried  out.  He  shall  have 
power  to  discharge  any  patient  when  he  considers  that  he  is  cured.  In 
case  of  a  disagreement  between  the  physician  and  the  contractor  as  to 
the  sanity  of  a  patient,  the  Governor  may  employ  some  other  physician 
to  consult  upon  the  case.  Whenever  a  patient  dies,  or  is  ordered  to  be 
discharged  by  the  physician,  the  Governor  and  the  Secretary  of  State 
shall  be  notified,  and  no  board  shall  be  paid  after  the  date  of  the  patient's 
death  or  the  order  for  his  discharge. 

The  courts  of  the  State  shall  have  power  to  commit  to  the  care  of  the 

'  General  Laws  of  Oree;on,  1843-1872,  pp.  361,  364,  62(X-623.     Laws  of  Oregon, 
1878,  pp.  71-77 ;  1880,  pp.  49-51 ;  1882,  pp.  4-6. 


508  APPENDIX  — PENNSYLVANIA. 

contractors  any  person  Avho  has  been  charged  with  an  offence  punishable 
with  imprisonment  or  death,  who  shall  have  been  found  to  be  insane  or 
idiotic,  and  who  continues  to  be  insane  or  idiotic. 

If  the  defence  in  any  criminal  case  be  the  insanity  of  the  defendant, 
and  he  is  found  not  guilty  on  that  ground,  the  court  must,  if  it  deems  his 
being  at  large  dangerous,  order  him  to  be  committed  to  any  lunatic 
asylum  authorized  by  the  State  to  receive  and  keep  such  persons  until 
he  becomes  sane,  or  is  discharged  according  to  law. 

Whenever  any  convict  confined  in  the  State  Prison  shall,  in  the  opinion 
of  the  physician  of  the  prison,  be  insane  or  idiotic,  the  physician  shall 
make  oath  to  the  same  before  the  county  judge  of  the  county  in  which 
the  prison  is  located.  The  judge  shall  summon  one  or  more  competent 
physicians  to  make  an  examination,  and,  if  in  their  opinion  the  convict 
is  of  unsound  mind,  the  judge  shall  report  the  case  to  the  Governor,  who 
may,  in  his  discretion,  cause  the  convict  to  be  removed  to  the  place  pro- 
vided for  the  insane  and  idiotic. 


PENNSYLVANIA.* 

The  trustees  of  any  asylum  for  the  insane  where  there  are  women  de- 
tained may  appoint  a  skilful  female  physician  to  have  charge  of  the  female 
patients. 

The  Board  of  Public  Charities  shall  appoint  a  committee  of  five  of  its 
members  to  act  as  the  committee  on  lunacy.  One  of  this  committee  shall 
be  a  member  of  the  bar,  and  one  a  practising  physician,  and  each  shall  be 
of  at  least  ten  years'  standing  in  his  profession.  The  committee  on  lunacy 
shall  examine  into  the  condition  of  the  insane  throughout  the  State,  and 
into  the  management  of  the  hospitals,  public  and  private,  and  all  other 
places  in  which  the  insane  are  kept  for  care  and  treatment  or  detention, 
.and  shall  make  an  annual  report.  The  board,  among  other  things,  shall 
have  power,  with  the  consent  of  the  chief  justice  of  the  supreme  court 
and  of  the  attorney -general,  to  make  rules  and  regulations : 

1.  For  the  licensing  of  all  asylums  and  places  where  more  than  one 
patient  is  kept,  excepting  jails  and  such  hospitals  as  may  be  specially  ex- 
empted from  the  duty  of  obtaining  a  license. 

2.  For  securing  the  proper  treatment  of  all  insane  persons  wherever 
kept,  and  to  guard  against  the  improper  detention  of  such  persons. 

3.  For  determining  the  forms  to  be  observed  in  committing,  trans- 
ferring, and  discharging  all  lunatics  except  those  committed  by  order  of 
a  court  of  record. 

■'  Brightlv's  Pardon's  Digest  of  Laws  of  Pennsylvania,  1700-1872,  Vol.  1,  pp.  27, 
391,  392.  Vol.  2,  pp.  969-989.  Purdon's  Annual  Digest,  1873-1878,  pp.  1893,  1894. 
Laws  of  Pennsylvania,  1879,  p.  98;  1881,  pp.  83,  84,  173  ;  1883,  pp.  21-30,  92. 


APPENDIX — PENNSYLVANIA.  509 

There  shall  be  appointed  in  each  county  where  there  is  a  house  or 
place  for  the  care  or  detention  of  the  insane  a  board  of  visitors  of  not 
less  than  three  persons.  AYomen  may  be  appointed  members  of  these 
boai'ds. 

The  board  of  public  charities  shall  make  rules  to  insure  to  the  patients 
the  admission  to  see  them  of  all  proper  visitors,  being  members  of  their 
family,  friends,  agents,  or  attorneys. 

No  person  shall  be  received  as  a  patient  for  treatment  or  for  detention 
into  any  house  or  place  where  more  than  one  insane  person  is  detained, 
or  into  any  house  or  place  where  one  or  more  insane  persons  are  detained 
for  compensation,  without  a  certificate  signed  by  at  least  two  physicians, 
residents  in  the  commonwealth,  who  have  been  in  the  practice  of  medicine 
for  at  least  five  years,  stating  that  they  have  examined  separately  the 
person  alleged  to  be  insane  and  believe  that  he  is  insane,  and  that  the 
disease  is  of  a  character  which  requires  that  the  person  should  be  placed 
in  a  hospital  or  other  establishment  for  care  and  treatment ;  that  they 
are  not  related  by  blood  or  marriage  to  the  patient,  nor  in  any  way  con- 
nected with  the  hospital  in  which  it  is  proposed  to  place  him.  This 
certificate  must  be  made  within  one  week  after  the  examination  of  the 
patient,  and  within  two  weeks  of  the  time  of  his  admission  to  the  hos- 
pital. It  shall  be  sworn  to  before  a  judge  of  the  county  where  the  ex- 
amination took  place,  and  the  judge  shall  certify  to  the  genuineness  of 
the  signatures,  and  to  the  standing  and  good  repute  of  the  signers. 

The  person  or  persons  requesting  the  admission  or  detention  shall  sign 
a  writing  stating  that  the  person  has  been  removed,  and  is  to  be  detained 
at  his  or  their  request  under  the  belief  that  such  detention  is  necessary 
and  for  the  benefit  of  the  insane  person.  There  shall  also  be  furnished 
to  the  persons  in  charge  of  the  hospital  or  house  a  statement  signed  by 
the  persons  requesting  the  detention  of  the  patient,  giving  his  name,  age, 
residence,  occupation,  and  a  list  of  his  relatives,  also  the  circumstances 
connected  with  the  patient's  insanity,  and  the  names  and  address  of  his 
medical  attendants  for  two  years. 

If,  through  inadvertence,  any  of  the  answers  are  omitted,  and  there  is 
no  reason  to  doubt  the  good  faith  of  the  parties,  the  patient  may  be 
received  and  kept,  if  Avithin  seven  days  the  statements  are  made  complete. 
The  regular  medical  attendant  of  the  house  shall,  within  twenty -four  hours 
after  the  reception  of  any  patient,  examine  him,  and  in  case  he  is  of  opinion 
that  a  detention  is  not  necessary  for  the  benefit  of  the  patient,  he  shall 
notify  the  person  or  persons  at  whose  instance  the  patient  is  detained, 
and  unless  within  seven  days  satisfactory  proof  is  exhibited  of  such 
necessity  the  patient  shall  be  discharged  and  restored  to  his  family  or 
friends.  At  the  time  of  such  examination  the  medical  attendant  shall 
inform  the  patient  that  if  he  desires  to  communicate  with  any  person  or 
persons  they  will  be  summoned,  and  any  proper  person  or  persons,  not 
exceeding  two,  shall  be  permitted  to  have  a  full  and  unrestrained  inter- 
view with  the  patient. 

The  statements  furnished  at  the  time  of  the  reception  of  the  patient, 
and  the  statement  of  the  medical  attendant  of  the  house,  shall  be  sent  to 
the  committee  on  lunacy,  and  there  shall  be  a  report,  at  least  once  in  six 
months,  by  the  medical  attendant,  on  the  condition  of  each  patient. 


510  APPENDIX  —  PENNSYLVANIA. 

Persons  detained  as  insane  may,  under  certain  restrictions  and  regula- 
tions, have  any  medical  practitioner  they  desire  to  treat  them  for  all 
maladies  other  than  insanity. 

All  persons  detained  as  insane  shall,  in  the  discretion  of  the  superin- 
tendent, be  allowed  to  correspond  under  seal  Avith  persons  outside  the 
asylum,  and  they  shall  have  the  unrestricted  privilege  of  writing  once  a 
month  to  any  member  of  the  committee  on  lunacy. 

All  persons  other  than  criminals,  who  have  been  detained  as  insane, 
shall,  as  soon  as  they  are  restored  to  reason,  in  the  opinion  of  the  medical 
attendant  of  the  house,  be  forthwith  discharged.  If  the  discharged 
patient  is  in  indigent  circumstances,  he  shall  be  furnished  with  raiment 
and  with  funds  sufficient  to  travel  to  his  home. 

The  committee  on  lunacy  shall  be  notified  of  all  discharges  within 
seven  days  thereafter. 

The  committee  on  lunacy  may  at  any  time  order  the  discharge  of  a 
patient  (other  than  a  person  committed  after  trial  and  conviction  for 
crime,  or  by  order  of  court).  But  such  order  shall  not  be  made  unless 
notice  is  first  given  to  the  person  in  charge  of  the  asylum,  and  to  the 
persons  who  caused  the  patient  to  be  detained,  and  the  committee  shall 
not  sign  an  order  for  discharge  unless  they  have  personally  examined  the 
case  of  the  patient. 

Persons  may  voluntarily  place  themselves  in  an  asylum  for  a  period 
not  exceeding  seven  days,  by  signing  an  agreement  giving  authority  to 
detain  them,  and  they  may  from  time  to  time  renew  the  authority  for 
periods  not  exceeding  seven  days  each  ;  but  every  such  agreement  must 
be  signed  in  the  presence  of  some  adult  person  attending  as  a  friend  of 
the  patient.  Such  agreement  must  also  be  signed  in  the  presence  of  the 
person  in  charge  of  the  house,  or  the  medical  attendant,  Avho  shall  him- 
self subscribe  it. 

Whenever  the  State  Board  of  Commissioners  of  Public  Charities  shall 
deem  it  expedient  to  transfer  any  indigent  insane  person  in  a  county 
poor-house,  or  almshouse,  or  otherwise  in  the  custody  of  the  directors  or 
overseers  of  the  poor,  to  the  State  hospitals  for  the  insane  for  care  and 
treatment,  they  shall  petition  the  president  judge  of  the  court  of  common 
pleas  of  the  proper  county,  who  shall  notify  the  directors  or  overseers  of 
the  poor  to  appear,  and  show  cause  why  such  removal  should  not  take 
place.  If,  upon  hearing,  the  judge  deem  it  best,  he  shall  make  an  order 
directing  the  removal  of  such  insane  person  to  the  State  hospital  for  the 
proper  district. 

The  expense  of  caring  for  indigent  insane  persons  in  the  State  hos- 
pitals shall  be  divided  between  the  State  and  the  county,  the  county  not 
paying  for  each  person  over  two  dollars  a  week. 

Insane  persons  may  be  placed  in  a  hospital  by  order  of  any  court  or 
law  judge  after  the  following  course  of  proceedings :  On  statement  in 
writing  of  any  respectable  person  that  a  certain  person  is  insane,  and 
requires  restraint,  the  judge  shall  appoint  at  once  a  commission  to  inquire 
into,  and  report  on,  the  facts  of  the  case.  This  commission  shall  be  com- 
posed of  three  persons,  one  of  whom,  at  least,  shall  be  a  physician,  and 
another  a  lawyer.     If,  after  hearing  the  evidence,  they  think  it  is  a  suit- 


APPENDIX — PENNSYLVANIA,  511 

able  case  for  confinement,  the  judge  shall  issue  his  wai-rant  for  such  dis- 
position of  the  insane  person  as  the  circumstances  of  the  case  require. 

If  an  insane  person  is  manifestly  suifering  from  want  of  proper  care, 
any  law  judge  shall  order  him  to  be  placed  in  some  hospital  for  the 
insane,  at  the  expense  of  those  legally  bound  to  support  him.  But  in 
every  such  case  there  must  be  notice  to  the  persons  affected,  and  a  hearing 
had  in  the  matter.  Persons  w^ho  have  voluntarily  bound  themselves  for 
the  support  of  any  patient  in  the  hospital,  may  remove  the  patient  to 
avoid  further  responsibility. 

Pennsylvania  State  Lunatic  Hospital.  —  The  admission  of  insane 
patients  from  the  several  counties  shall  be  in  the  ratio  of  their  insane 
population.  Paying  patients  shall  pay  according  to  the  terms  directed 
by  the  trustees.  Indigent  persons  and  paupers  shall  be  supported  in  the 
hospital  by  the  townships  and  counties  to  which  they  are  chargeable. 
The  several  constituted  authorities  having  care  of  the  poor  in  the  several 
counties  and  towns  shall  have  authority  to  send  to  the  asylum  such  insane 
paupers  as  they  deem  proper  inmates. 

If  any  person  shall  apply  to  any  court  of  record,  having  jurisdiction 
of  offences  which  are  punishable  by  imprisonment  for  ninety  days  or 
more,  for  the  commitment  to  the  asylum  of  any  insane  person  within  the 
county,  it  shall  be  lawful  for  such  court  to  either  inquire  into  the  fact  of 
insanity  in  a  summary  way,  giving  due  notice  to  the  alleged  lunatic  and 
his  friends  or  kindred,  or  by  awarding  an  inquest,  at  the  option  of  the 
court.  If  the  court  is  satisfied  that  such  person  is  by  reason  of  insanity 
unfit  to  be  at  large,  or  is  suffering  any  unnecessary  duress  or  hardship, 
it  shall  commit  the  person  to  the  asylum  ;  but  in  all  cases  the  court  may 
use  its  discretion  in  sending  any  insane  person  to  the  hospital,  and  may 
cause  him  to  be  confined  elsewhere  if  it  believes  the  case  incurable.  In 
order  of  admission,  the  indigent  are  to  have  precedence  over  the  rich, 
and  if  there  is  not  room  for  all,  recent  cases  shall  have  preference  over 
those  of  long  standing. 

The  friends  or  relatives  of  any  insane  person,  a  patient  in  the  hospital, 
may  apply  to  the  court  of  common  pleas  of  Dauphin  County,  or  to  the 
president  judge  of  said  court  in  vacation,  to  deliver  over  to  them  the 
person  there  confined.  The  court  or  judge,  if  it  is  safe  for  the  com- 
munity, may  do  this,  provided  security  is  given  that  such  lunatic  shall 
do  no  injury  to  the  person  or  property  of  anyone  when  at  large. 

The  courts  may  commit  to  the  asylum  any  person  who,  having  been 
charged  with  an  offence  punishable  by  imprisonment  or  death,  shall  be 
found  to  have  been  insane  at  the  time  the  offence  was  committed,  and 
who  still  continues  insane. 

If  any  prisoner  confined  in  the  Eastern  Penitentiary  develops  such 
marked  insanity  as  to  render  continued  confinement  in  the  penitentiary 
improper,  and  removal  to  the  State  Lunatic  Hospital  necessary  to  his 
restoration,  the  inspectors  of  the  penitentiary  shall  submit  the  case  to  a 
board  composed  of  the  district  attorney  of  the  county  of  Philadelphia, 
the  principal  physician  of  the  Pennsylvania  Hospital  for  the  Insane  at 
Philadelphia,  and  the  principal  physician  of  the  Friends'  Insane  Asylum 
at  Frankford,  and  in  case  a  nuyority  cannot  at  any  time  when  required 
attend,  a  competent  physician  or  physicians  shall  be  appointed  by  the 


512  APPENDIX  — PENNSYLVANIA. 

court  of  quarter  sessions  of  the  county  of  Philadelphia  in  the  place  oi 
such  as  cannot  attend.  If  any  two  of  the  board  certify  that  the  prisoner 
is  insane,  the  Governor  shall,  if  he  approves,  direct  that  the  insane  pris- 
oner be  removed  to  the  State  Lunatic  Hospital.  If  any  such  insane 
prisoner  in  the  hospital  so  far  recovers,  before  his  sentence  has  expired, 
that  his  return  to  the  penitentiary  will  be  safe  and  proper,  the  trustees 
shall  cause  such  prisoner  to  be  returned  to  the  penitentiary.  Due  notice 
of  all  such  removals  or  transfers  shall  be  given  to  the  clerk  of  the  court 
of  quarter  sessions  of  the  county  from  which  such  prisoners  were  sent  to 
the  penitentiary. 

No  person  shall  be  sent  to  this  lunatic  hospital  who  shall  have  been 
charged  with  homicide,  or  of  having  attempted  to  commit  the  same,  or  to 
commit  any  arson,  rape,  robbery,  or  burglary,  and  have  been  acquitted  of 
any  such  offence  on  the  ground  of  insanity.  Where  the  court  trying 
such  person,  or  hearing  the  case,  shall  be  satisfied  that  it  is  dangerous  for 
such  lunatic  to  be  at  large  on  account  of  having  committed  or  attempted 
to  commit  either  of  the  crimes  aforesaid,  such  person  shall  be  continued 
in  the  penitentiary  or  the  prison  of  the  county ;  provided  that  the  court 
may  send  the  person  to  said  lunatic  hospital,  if  it  is  satisfied  that  a  cure 
of  the  insanity  may  be  speedily  effected  by  so  doing. 

In  every  case  of  an  insane  criminal  or  a  dangerous  lunatic  sent  to  the 
asylum,  if  the  trustees  of  the  asylum  and  the  superintending  physician 
are  satisfied  there  is  no  reasonable  prospect  of  a  cure  of  the  insanity 
being  effected  by  a  retention  of  the  lunatic  in  the  hospital,  they  shall 
cause  him  to  be  removed  to  the  prison  of  the  proper  county,  or  to  the 
penitentiary  from  which  he  was  sent. 

Western  Pennsylvania  Hospital. — Beside  provisions  in  substance  the 
same  as  those  in  regard  to  commitment  to  and  discharge  from  the  Penn- 
sylvania State  Lunatic  Hospital,  it  is  further  specially  provided  as 
follows :  Any  indigent  insane  patients,  not  criminals,  that  are  regai'ded 
by  the  board  of  managers  of  the  hospital  and  the  physician  as  incurable, 
shall  be  returned  to  the  constituted  authorities  having  charge  of  the  poor 
in  the  city,  township,  or  poor  district,  which  may  be  chargeable  with  the 
support  of  such  poor  patients.  If  any  criminal  a  patient  in  the  hospital 
recovers  his  sanity,  the  sheriff  shall  be  notified,  and  thereupon  such 
sheriff  shall  remove  such  person  to  the  jail  of  the  proper  county,  there 
to  be  held  in  strict  custody  subject  to  the  further  order,  decree,  or  sentence 
of  the  court  by  which  he  was  committed  to  the  hospital.  If  any  indigent 
patient  is  cured  of  his  insanity,  the  principal  physician  shall  notify  the 
commissioners  of  the  proper  county  to  remove  such  cured  person  from  the 
hospital. 

If  any  county  liable  for  the  support  of  insane  patients  fails  for  a 
period  of  three  months  to  pay  the  amount  due  for  such  support,  the 
managers  of  the  hospital  may  return  to  the  jail  of  the  said  county  those 
insane  persons  whose  expenses  remain  unpaid,  excepting  those  cases 
which  have  been  sent  to  the  hospital  from  the  penitentiary. 

Miscellaneous  Provisions. — It  shall  be  lawful  for  any  court  of  common 
pleas  to  issue  a  commission  to  inquire  into  the  lunacy  of  any  person  in 
the  commonwealth,  or  having  property  therein.  On  the  return  of  any 
inquisition  finding  that  the  person  named  is  a  lunatic,  the  court  may 


APPENDIX- — PENNSYLVANIA.  513 

commit  the  custody  and  care  of  the  person,  or  estate,  or  both,  to  such 
person  or  persons  as  they  deem  most  suitable.  Whenever  any  person 
shall  be  found  by  inquisition  to  be  insane,  the  committee  of  the  person 
or  of  the  estate  of  such  insane  person,  and  also  the  clerk  of  the  court 
into  which  the  inquisition  has  been  returned,  shall  forthwith  send  to  the 
committee  on  lunacy  a  statement  signed  by  the  committee  of  the  lunatic 
giving  the  name,  age,  sex,  and  residence  of  the  lunatic,  and  the  residence 
of  the  committee ;  and,  upon  any  change  in  the  residence  or  place  of 
detention  of  the  lunatic,  notice  shall  forthwith  be  given  to  the  committee 
on  lunacy.  The  committee  on  lunacy  shall  have  power  to  visit,  examine, 
and  look  after  such  lunatic,  and  may  apply  to  the  proper  court  to  make 
such  orders  for  the  care  or  maintenance  of  the  lunatic  as  the  case  may 
require.  Appeal  from  any  order  thus  made  may  be  taken  to  the  supreme 
court.  Adjudged  lunatics  shall  not  be  arrested  on  civil  process,  and,  if 
they  are  so  arrested,  shall  be  discharged  by  tlie  court  from  which  the 
process  issued. 

If  any  person  not  an  adjudged  lunatic  is  imprisoned  in  any  civil  action 
and  appears  to  be  insane,  the  jailer  shall  notify  two  or  more  aldermen  or 
justices  of  the  peace,  who  shall  attend  at  the  jail  and  make  an  examina- 
tion, and,  if  they  find  the  prisoner  of  unsound  mind,  they  shall  certify 
the  same  to  the  prothonotary  of  the  court  of  common  pleas  of  the  county. 
He  shall  bring  the  matter  before  the  court,  and  a  day  shall  be  fixed  for  a 
hearing,  and  the  creditor,  plaintiif  in  the  case,  shall  be  notified.  If  the 
court,  on  hearing  the  case,  is  satisfied  that  the  prisoner  is  insane,  an 
order  shall  be  made  for  his  discharge  from  confinement ;  provided  that  if 
it  appears  to  the  court  that  he  is  not  fit  to  go  at  large,  the  court  may  make 
an  order  that  he  be  detained  in  custody  or  delivered  to  his  kindred 
or  friends  in  the  manner  provided  in  the  case  of  a  lunatic  charged  with  a 
crime  or  misdemeanor. 

Whenever  upon  the  trial  of  any  person  charged  with  a  crime  or  mis- 
demeanor it  is  given  in  evidence  that  such  person  was  insane  at  the  time 
of  the  commission  of  such  offence,  and  he  is  acquitted  by  the  jury 
especially  on  this  ground,  the  court  may  order  him  to  be  committed  to  some 
place  of  confinement  for  safe  keeping  or  treatment.  If  after  a  confinement 
of  three  months  any  law  judge  is  satisfied  that  the  prisoner  has  recovered, 
and  that  the  paroxysm  of  insanity  in  which  the  criminal  act  was  com- 
mitted was  the  first  and  only  one  he  had  ever  experienced,  he  may  order 
his  unconditional  discharge ;  if,  however,  it  appear  that  such  paroxysm 
of  insanity  was  preceded  by  at  least  one  other,  then  the  court  may  in  its 
discretion  appoint  a  guardian  of  his  person  and  commit  the  care  of  the 
prisoner  to  him,  the  guardian  giving  bonds  to  pay  for  any  damage 
his  ward  may  commit ;  provided  always,  that  in  case  of  homicide,  or 
attempted  homicide,  the  prisoner  shall  not  be  discharged  unless,  in  the 
unanimous  opinion  of  the  superintendent  and  the  managers  of  the  hospital 
and  the  court  before  which  the  prisoner  was  tried,  he  has  recovered  and 
is  safe  to  be  at  large.  If  a  person  indicted  for  an  offence  shall,  upon 
arraignment  or  upon  the  trial,  be  found  to  be  a  lunatic,  the  court  shall 
proceed  to  confine  him  as  above  stated.  In  every  case  in  which  a  person 
charged  with  any  offence  is  brought  before  the  court  to  be  discharged  for 
want  of  prosecution,  and  shall,  by  the  oath  of  one  or  more  credible  persons, 

33 


514  APPENDIX — PENNSYLVANIA. 

appear  to  be  insane,  the  court  shall  order  the  district  attorney  to  send 
before  the  grand  jury  a  written  allegation  of  such  insanity,  and  the  grand 
jury  shall  make  inquiry  into  the  case,  and  make  presentment  of  their 
finding,  and  thereupon  the  court  shall  order  a  jury  to  be  impanelled 
to  try  the  insanity  of  such  person.  Notice  of  the  trial  shall  be  given  to 
the  next  of  kin,  and,  if  the  jury  find  such  person  insane,  he  shall  be 
committed  by  the  court  as  aforesaid. 

If  the  kindred  or  friends  of  any  person  who  may  have  been  acquitted 
as  aforesaid  on  the  ground  of  insanity,  or,  in  default  of  such  kindred  or 
friends,  the  guardians,  overseers,  or  supervisors  of  any  county,  township, 
or  place,  shall  give  proper  security  that  such  lunatic  shall  be  restrained 
from  the  commission  of  any  oifence,  the  court  may  make  an  order  for  his 
delivery  to  his  kindred  or  friends,  or  to  such  guardians,  overseers,  or 
supervisors. 

Whenever  any  person  is  imprisoned,  either  convicted  of  any  crime,  or 
charged  with  any  crime,  and  acquitted  on  the  ground  of  insanity,  appli- 
cation in  writing,  under  oath,  stating  that  such  prisoner  is  believed  to  be 
insane,  and  requesting  that  such  prisoner  be  removed  to  a  hospital  for 
the  insane,  may  be  made  to  any  judge  of  any  court  having  immediate 
cognizance  of  the  crime  with  which  such  prisoner  is  charged,  or  of  the 
court  by  which  such  prisoner  has  been  convicted,  to  appoint  a  commission 
of  three  citizens.  One  of  the  commissioners  shall  be  of  the  profession  of 
medicine  and  one  of  the  profession  of  law,  and  it  shall  be  their  duty  to 
inquire  into  and  report  upon  the  mental  condition  of  the  prisoner.  If, 
by  the  report  of  the  commissioners,  it  appears  that  the  prisoner  is  of 
unsound  mind  and  unfit  for  penal  discipline,  the  judge  issuing  the  com- 
mission, or  any  other  judge  of  the  same  court,  may  make  an  order  di- 
recting the  removal  of  such  prisoner  to  the  State  Hospital  for  the  Insane 
nearest  to  the  place  of  imprisonment,  there  to  be  kept  and  cared  for : 
Provided,  that  whenever  a  hospital  is  established  by  the  State  especially 
for  the  care  of  insane  crimirals,  the  order  of  removal  shall  be  to  that 
hospital. 

In  all  cases  where  any  person  who  may  have  committed  any  criminal 
act  and  is  dangerous  to  the  community  shall  be  found  to  be  insane  in  the 
manner  provided  by  law,  any  court  having  cognizance  of  the  ofience  with 
which  such  person  is  charged  may  commit  him  to  the  proper  asylum  for 
the  insane,  to  remain  until  restored  to  sanity. 

Whenever  any  person  sent  to  the  hospital  under  these  provisions  has 
been  so  far  restored  to  mental  sanity  as  no  longer  to  need  the  care  or 
restraint  of  the  hospital,  the  judge  who  committed  him  may,  if  the  term 
of  imprisonment  for  which  such  prisoner  was  sentenced  has  not  expired, 
remand  him  to  prison  to  serve  out  the  unexpired  term  of  sentence,  or  if 
such  prisoner  became  unsound  in  mind  after  the  alleged  crime  and  before 
conviction,  the  judge  may  remand  such  prisoner  for  trial ;  but,  if  the 
term  for  which  such  prisoner  was  sentenced  has  expired,  or  if  the  crime 
with  which  the  prisoner  is  charged  was  committed  during  his  probable 
insanity,  the  judge  may  order  the  patient  to  be  discharged.  If  the  term 
of  sentence  expires  while  the  prisoner  remains  uncured  in  the  hospital, 
the  judge,  upon  the  due  application  of  relatives  or  friends  of  such  patient, 
and  upon  proper  security  being  given  for  the  custody  and  care  of  such 


APPENDIX — RHODE    ISLAND.  516 

insane  person,  may  make  an  order  for  his  discharge  from  the  hospital 
and  delivei'y  into  the  control  of  the  person  or  persons  applying  therefor. 

Insane  criminals  in  custody  shall  not  be  received  into  an  asylum  except 
when  delivered  by  a  sheriff  of  the  county,  or  his  deputy,  together  with  an 
order  of  the  proper  court.  Nor  shall  such  criminals  be  discharged  from 
a  hospital,  or  other  place  of  detention,  save  on  a  like  order,  and  to  the 
sheriff,  or  his  deputy,  producing  the  order. 

Whenever  any  person  detained  in  any  jail  or  prison  is  insane,  or  in 
such  a  condition  as  to  require  treatment  in  a  hospital  for  the  insane,  it 
shall  be  the  duty  of  any  law  judge  of  the  court,  under  whose  order  the 
person  is  detained,  upon  application,  to  direct  an  inquiry  into  the  circum- 
stances, either  by  a  commission  or  otherwise,  as  he  shall  deem  proper, 
with  notice  to  the  committee  on  lunacy  ;  and,  if  the  judge  shall  be  satisfied 
that  the  prisoner  requires  treatment  in  a  hospital,  he  shall  direct  the  re- 
moval of  the  person  from  the  jail  or  prison  to  a  State  hospital. 

The  trustees,  managers,  and  physician  of  any  hospital  in  which  a 
criminal  is  confined  by  order  of  any  court,  or  to  which  a  lunatic  has 
been  committed  after  an  acquittal  of  crime,  shall  not  discharge  the 
prisoner,  or  lunatic,  without  the  order  of  a  court  of  competent  jurisdic- 
tion ;  and  in  case  such  lunatic,  whether  a  convict  or  acquitted,  is  not  set 
at  large,  but  is  to  be  removed  to  any  place  of  custody  other  than  a  hos- 
pital, the  order  for  removal  shall  not  be  made  without  notice  to  the  com- 
mittee of  lunacy,  and  time  given  them  to  investigate  the  case  and  be 
heard. 


RHODE  ISLAND.^ 

Whenever  any  person  is  a  lunatic,  or  so  furiously  mad  as  to  render  it 
dangei'ous  for  him  to  be  at  large,  any  trial  justice  or  clerk  of  a  justice 
court  within  the  county,  on  complaint  in  writing,  under  oath,  shall  issue 
his  warrant,  directing  that  such  person  be  brought  before  that  or  some 
other  justice  court  for  examination.  If  the  court,  on  such  examination, 
find  the  complaint  true,  it  shall,  unless-  security  is  given  that  said  insane 
person  shall  not  be  permitted  to  go  at  large  until  restored  to  soundness 
of  mind,  commit  such  person  either  to  the  Butler  Hospital  for  the  Insane 
or  to  the  State  Asylum  for  the  Insane.  Such  patient  shall  be  detained 
in  the  hospital  until  it  is  found  by  some  justice  court  of  the  county  where 
he  is  detained  that  he  is  restored  to  soundness  of  mind,  or  is  no  longer 
under  need  of  restraint,  or  until  security  is  given  to  the  court,  as  afore- 
said, for  his  safe  keeping.  The  expense  of  caring  for  any  such  lunatic 
shall  be  paid  out  of  his  estate,  if  he  has  any;  if  he  has  no  estate,  then 
by  the  town  liable  for  his  support. 

'  Public  Statutes  of  Rhode  Island,  1882,  pp.  195-204,  425,  430,  446,  467,  720. 
Acts  and  Resolves,  R.  I.,  January  session,  1883,  pp.  129,  130,  146. 


516  APPENDIX  —  RHODE    ISLAND. 

On  petition,  stating  that  any  person  is  insane,  and  ought  to  be  placed 
in  a  hospital,  or  restrained,  any  justice  of  the  supreme  court  may  forth- 
with appoint  not  less  than  three  commissioners  to  inquire  into  and  report 
all  facts  bearing  on  the  case,  together  with  their  opinion  whether  such 
person,  if  insane,  should  be  placed  in  one  of  the  insane  asylums.  The 
commissioners  shall  fix  a  time  for  a  hearing,  give  notice  to  the  party 
alleged  to  be  insane,  hear  all  evidence  ofiered,  and  make  an  examination 
of  the  supposed  insane  person.  The  court  may,  pending  the  inquisition, 
give  directions  for  the  care  and  restraint  of  such  insane  person,  and  may, 
if  necessary,  commit  him  to  one  of  the  asylums,  or  to  the  county  jail,  as 
is  most  convenient  and  proper.  On  the  coming  in  of  the  report  of  the 
commissioners,  the  justice  may  order  the  person  complained  of  to  be  con- 
fined in  the  Butler  Hospital  for  the  Insane,  or  at  the  State  Asylum  for 
the  Insane,  or  in  some  other  curative  hospital  for  the  insane  of  good 
repute  within  or  without  the  State,  or  may  dismiss  the  petition  altogether. 

Any  person  thus  committed  may,  although  not  restored  to  sanity,  be 
discharged  from  the  asylum  upon  the  written  recommendation  of  the 
trustees  and  superintendent  of  the  asylum,  by  an  order  of  any  justice  of 
the  supreme  court,  made  in  his  discretion. 

The  parents  or  guardian  of  any  insane  person,  if  he  have  any,  and,  if 
not,  his  relatives  and  friends,  or,  if  a  pauper,  the  overseers  of  the  poor 
of  the  town  to  which  he  is  chargeable,  may  have  him  removed  to  and 
placed  in  the  Butler  Hospital  or  State  Asylum  for  the  Insane,  if  he  can 
be  there  received ;  and  if  not,  in  any  other  hospital  for  the  insane  of 
good  repute,  managed  under  the  supervision  of  a  board  of  ofiicers  ap- 
pointed under  the  authority  of  this  or  some  other  State;  but  the  super- 
intendent of  such  hospital  shall  not  receive  any  person  into  his  custody 
in  such  case  without  a  certificate  from  two  practising  physicians  of  good 
standing  that  such  person  is  insane. 

Any  persons  who,  of  their  own  accord,  without  any  obligation  imposed 
by  law,  have  become  responsible  for  the  payment  of  the  expenses  of  any 
insane  person  in  an  asylum,  may,  if  it  is  necessary  in  order  to  terminate 
further  responsibility  on  their  part,  remove  such  person  therefrom. 

The  superintendent  of  any  asylum  for  the  insane  within  the  State 
may,  on  the  application  of  any  relative  or  friend,  and  with  the  approba- 
tion in  writing  of  the  visiting  committee  of  the  trustees,  discharge  any 
person  not  committed  by  process  of  law. 

On  petition  to  a  justice  of  the  supieme  court  by  some  person,  not  an 
inmate  of  the  asylum,  setting  forth  that  he  has  reason  to  believe,  and  does 
believe,  that  a  person  confined  therein  is  not  insane,  and  is  unjustly  de- 
prived of  his  liberty,  the  justice,  in  his  discretion,  may  issue  a  commission, 
such  as  has  been  described  above,  to  inquire  into  the  patient's  condition. 
No  person  shall  visit  or  examine  the  patient,  except  the  commissioners, 
and  they  only  at  the  asylum,  and  not  elsewhere.  On  the  coming  in  of 
the  commissioners'  report,  the  court  may  confirm  or  disallow  the  same, 
and  order  the  discharge  of  such  person,  or  dismiss  the  petition  altogether, 
as  the  truth  shall  seem  to  require.  It  is  not  intended  by  any  of  these 
provisions  to  impair  or  abridge  the  right  to  the  writ  of  habeas  corpus. 
No  commission  for  the  purpose  of  committing  or  discharging  an  insane 
person  shall  be  issued  by  a  justice  of  the  supreme  court,  as  above  stated, 


APPENDIX  —  RHODE    ISLAND.  517 

until  the  person  applying  therefor  has  given  security  for  the  payment  of 
all  expenses  of  the  proceedings,  and  for  the  support  of  the  insane  person 
in  the  asylum,  if  committed  thereto. 

Whenever  any  person  imprisoned,  awaiting  trial,  in  a  criminal  case,  is 
deemed  insane,  the  Agent  of  State  Charities  and  Corrections,  or  the  clerk 
of  the  supreme  court  or  court  of  common  pleas,  in  any  county  of  the 
State  other  than  the  county  of  Providence,  may  petition  any  justice  of 
the  supreme  court  to  make  an  examination.  If,  upon  such  examination, 
the  justice  is  satisfied  that  the  person  thus  imprisoned  is  insane  or  idiotic, 
he  may  order  the  removal  of  such  prisoner  from  the  jail  to  the  State 
Asylum  for  the  Insane,  if  he  can  be  there  received ;  if  not,  to  the  Butler 
Hospital  for  the  Insane.  Upon  the  restoration  to  reason  of  any  person 
so  removed,  any  one  of  the  justices  of  the  supreme  court,  in  his  discre- 
tion, may  order  that  the  prisoner  be  remanded  to  the  place  of  his  original 
confinement,  to  await  his  trial  for  the  offence  for  which  he  stands  com- 
mitted. 

Whenever,  on  the  trial  of  any  person  upon  an  indictment,  the  accused 
shall  set  up  in  defence  his  insanity,  and  the  jury  shall  acquit  him  on  that 
ground,  the  court,  if  it  deem  the  going  at  large  of  such  person  dangerous 
to  the  public  peace,  shall  certify  its  opinion  to  the  Governor  of  the  State. 
The  Governor  may  make  provision  for  the  support  of  the  person  so 
acquitted,  and  cause  him  to  be  removed  to  the  State  Asylum  for  the 
Insane,  or  other  institution  for  the  insane,  either  within  or  without  the 
State,  during  the  continuance  of  such  insanity.  The  expenses  of  his 
maintenance  shall  be  paid  by  the  State,  but  may  be  collected  out  of  the 
estate  of  such  insane  person,  if  he  has  any. 

On  petition  of  the  Board  of  State  Charities  and  Corrections,  stating  that 
any  person  convicted  of  crime,  and  imprisoned  for  the  same  in  the  State 
Prison,  or  in  the  Providence  county  jail ;  or,  on  petition  of  the  clerks  of 
the  supreme  court  or  court  of  common  pleas,  in  the  other  counties  of  the 
State,  that  any  convict  in  the  jails  of  their  respective  counties  is  insane, 
idiotic,  or  in  such  a  state  of  impairment  of  body,  or  mind,  or  both,  as 
tends  directly  to  insanity,  idiocy,  or  dementia,  or  to  a  permanent  incapa- 
city for  mental  or  physical  labor,  any  justice  of  the  supreme  court  may, 
in  his  discretion,  order  an  examination.  If,  upon  such  examination,  said 
justice  is  satisfied  that  the  convict  is  insane,  or  in  any  of  the  states  of 
mind  or  body  above  mentioned,  he  may  order  the  removal  of  such  pris- 
oner from  the  State  Prison,  or  any  of  the  said  jails,  to  the  State  Asylum 
for  the  Insane,  the  State  Almshouse,  or  to  Butler  Hospital,  as,  in  his 
judgment,  he  shall  deem  best.  Such  order  of  removal  shall  be  only 
during  the  term,  and  until  the  expiration  of  the  prisoner's  sentence. 

Upon  restoration  to  reason  or  to  health,  both  of  body  and  mind,  of  the 
prisoner,  either  of  the  justices  of  the  supreme  court  may,  in  his  discre- 
tion, remand  him  to  the  place  of  his  original  confinement,  to  serve  out 
the  remainder  of  his  term  of  sentence. 

The  Agent  of  State  Charities  and  Corrections  and  the  Secretary  of  State 
shall  constitute  a  commission  to  visit  and  examine  all  places  and  institu- 
tions in  the  State  where  insane  persons  are  confined,  and  to  receive  and 
examine  all  complaints,  communications,  and  letters  from,  or  relating  to, 
any  insane  person,  or  person  alleged  to  be  insane.    They  shall  investigate 


518  APPENDIX  —  SOUTH    CAROLINA. 

any  case  that  seems  to  require  it,  and,  in  their  discretion,  may  petition  a 
justice  of  the  supreme  court  to  have  an  examination  made  of  any  person's 
condition,  in  the  manner  above  described,  and  said  justice  may,  in  his 
discretion,  cause  the  person  restrained  to  be  discharged. 

Whenever  the  Agent  of  State  Charities  and  Connections  shall  make 
complaint,  in  writing,  to  the  supreme  court  that  any  person  reputed  to 
be  idiotic,  lunatic,  or  insane,  is  not  humanely  or  properly  cared  for,  or  is 
improperly  restrained  of  his  liberty,  in  any  town,  the  court  shall  examine 
into  the  circumstances  of  the  case,  and,  if  the  complaint  is  found  true, 
shall  order  and  cause  such  idiotic,  lunatic,  or  insane  person  to  be  removed 
to  the  State  Asylum  for  the  Insane. 

Every  pauper  lunatic,  having  no  legal  settlement  in  the  State,  who,  in 
the  opinion  of  the  Board  of  State  Charities  and  Corrections,  is  insane,  shall 
be  sent  by  said  board  to  the  State  Almshouse,  or  to  the  State  Asylum 
for  the  Insane,  there  to  be  maintained  at  the  expense  of  the  State.  The 
board  may  send  to  this  asylum  any  insane  pauper  who  has  a  legal  settle- 
ment in  any  town,  to  be  kept  on  such  terms  as  may  be  agreed  upon.  The 
Agent  of  State  Charities  and  Corrections  shall  visit  all  town  asylums  and 
all  places  where  any  insane  person  is  kept,  to  see  that  no  insane  person 
is  improperly  confined  or  improperly  cared  for,  and  he  may  discharge  at 
any  time  from  any  institution  any  insane  person  who  has  been  committed 
thereto  upon  his  order.  No  insane  pauper  shall  be  detained  in  any  town 
asylum,  poor-house,  lockup,  or  bridewell  for  a  longer  period  than  five 
days,  unless,  in  the  opinion  of  the  Agent  of  State  Charities  and  Correc- 
tions, he  is  properly  cared  for. 

The  Board  of  State  Charities  and  Corrections  may  receive  for  treatment 
and  care  any  person  who  shall  be  an  inhabitant  of  the  State  who,  in  their 
opinion,  is  insane,  upon  such  terms  for  treatment  and  care  as  may  be 
agreed  upon  between  said  board  and  some  responsible  person,  upon  the 
written  certificate  of  two  practising  physicians  that,  in  their  opinion,  such 
person  is  insane. 


SOUTH  CAROLINA.^ 

The  following  persons  shall  be  entitled  to  admission  as  patients  to 
the  State  Hospital  for  the  Insane :  (1)  All  persons  found  to  be  idiots 
or  lunatics  by  inquisition  from  the  probate  or  circuit  courts,  or  on  trial 
in  the  circuit  court.  (2)  Where  the  admission  is  requested  by  the 
husband  or  wife,  or,  where  there  is  no  husband  or  wife,  by  the  next  of  kin 
of  the  idiot  or  lunatic.  (3)  All  persons  declared  lunatics,  idiots,  or 
epileptics,  after  due  examination  by  one  trial  justice  and  two  licensed 

»  General  Statutes  of  South  Carolina,  1882,  pp.  25,  270,  472-476,  751.     The  Code 
of  Civil  Procedure  of  South  Carolina  [bound  with  Gen.  Stats.],  pp.  15,  21,  22. 


APPENDIX  — SOUTH    CAROLINA.  519 

practising  physicians  of  the  State.  In  the  case  of  a  pauper,  the  ad- 
mission shall  be  at  the  request  of  the  county  commissioners  of  the 
county  where  the  pauper  has  his  legal  settlement ;  otherwise  the  admis- 
sion shall  be  at  the  request  of  the  husband  or  wife  or  next  of  kin  of  the 
idiot,  lunatic,  or  epileptic. 

Idiots  and  lunatics  from  other  States  may,  when  there  is  room  in  the 
asylum,  be  admitted  on  such  evidence  of  their  lunacy  or  idiocy  as  the 
regents  regard  suiBcient,  and  they  shall  pay  the  same  rates  as  citizen 
subjects. 

No  lunatic,  idiot,  or  epileptic,  declared  a  fit  subject  for  the  asylum  by 
a  trial  justice  and  two  physicians,  or  sent  from  another  State,  shall 
be  retained  in  the  institution  more  than  ten  days,  unless  an  order  for  his 
retention  is  made  by  the  medical  attendant  and  three,  at  least,  of  the 
regents  of  the  asylum  after  a  full  examination  of  the  patient's  state  of 
mind.  Upon  such  order  being  made,  the  secretary  of  the  board  of 
regents  shall  make  out  certified  copies  of  the  papers  in  the  case  and  send 
them  to  the  judge  of  probate  of  the  county  where  the  patient  resides,  and 
said  judge  shall  thereupon  make  such  order  in  regard  to  the  custody  of 
the  estate  of  the  lunatic  as  Avould  have  been  made  had  the  proceedings 
been  under  a  writ  de  lunatico  inquirendo. 

Whenever  a  judge  of  probate  or  a  judge  of  the  circuit  court  shall  direct 
any  trial  justice  to  inquire  as  to  the  idiocy,  lunacy,  or  epilepsy  of  any 
person,  or  when  information  on  oath  shall  be  given  to  any  trial  justice 
that  a  person  is  an  idiot,  lunatic,  or  epileptic,  and  is  a  pauper,  such  trial 
justice  forthwith  shall  call  to  his  assistance  two  licensed  practising 
physicians  and  examine  such  person  and  hear  the  evidence  in  the  case. 
If  after  full  examination  they  find  such  person  an  idiot,  lunatic,  or 
epileptic,  they  shall  certify  either  to  the  said  judge  or  to  the  board  of 
county  commissioners  whether,  in  their  opinion,  such  person  is  curable  or 
incurable,  and  whether  or  not  he  is  dangerous  to  be  at  large,  and  thereupon 
the  judge  or  the  board  of  county  commissioners,  in  his  or  its  discretion, 
may  order  that  the  person  be  sent  to  the  lunatic  asylum. 

The  judge  of  the  probate  court  may  commit  to  the  lunatic  asylum  any 
idiot,  lunatic,  or  person  non  compos  mentis,  who,  in  his  opinion,  is  so 
furiously  mad  as  to  be  unfit  to  be  at  large.  In  all  cases  the  judge  shall 
certify  in  what  place  the  said  person  resided. 

No  patient  shall  be  admitted  to  the  asylum  until  the  expenses  of  one- 
half  year,  or  of  such  shorter  time  as  the  nature  of  the  case  seems  to 
require,  shall  be  paid  in  advance.  A  bond  shall  be  given  to  secure  the 
payment  of  all  expenses ;  but  such  bond  shall  not  be  required  of  the 
county  commissioners  sending  a  pauper  patient  to  the  institution. 

Whenever  any  lunatic  or  epileptic  shall  have  recovered,  it  shall  be  the 
duty  of  the  regents  to  discharge  him  from  the  asylum.  Upon  due  notice 
from  the  superintendent  of  the  asylum,  the  county  commissioners  of  the 
various  counties  shall  remove  their  imbeciles  from  the  asylum,  and  shall 
take  care  of  such  persons  in  their  respective  county  poor-houses. 

It  has  been  recently  enacted  that  before  any  insane  person  not  ofiered 
as  a  pay  patient  is  admitted  to  the  asylum,  the  county  commissioners 
shall  investigate  and  see  upon  what  footing  the  patient  shall  be  admitted. 


620  APPENDIX  — TENNESSEE, 

and  whether  or  not  he  is  able  to  pay  some  part  of  the  expense  of  his 
suppol't. 

In  criminal  cases,  any  judge  of  the  circuit  court  is  authorized  to  send 
to  the  lunatic  asylum  any  person  charged  with  the  commission  of  any 
offence,  who  shall  upon  the  trial  before  him  prove  to  be  non  compos 
mentis,  and  the  judge  is  authorized  to  make  all  necessary  orders  to  carry 
into  effect  this  power. 

No  pauper  lunatic,  idiot,  or  epileptic,  shall  be  confined  for  safe 
keeping  in  any  jail ;  and  if  any  such  person  shall  be  imprisoned  under, 
and  by  virtue  of,  any  legal  process,  it  shall  be  the  duty  of  the  sheriff,  in 
whose  custody  he  may  be,  to  obtain  his  discharge  as  speedily  as  possible, 
and  send  him  forthwith  to  the  asylum,  according  to  law. 

The  county  commissioners  shall  be  authorized  to  send  all  pauper 
lunatics,  idiots,  and  epileptics,  in  their  several  counties,  to  the  lunatic 
asylum. 


TENNESSEE.' 


Each  county  is  entitled  to  send  to  the  hospital  its  due  proportion,  both 
of  private  and  pauper  patients,  according  to  its  population  and  the  number 
of  its  insane,  but  not  more  than  one  non-paying  patient  to  each  four 
thousand  inhabitants.  Each  senatorial  district  is  entitled  to  send  four 
pauper  patients  at  the  expense  of  the  State. 

No  person  shall  be  received  as  a  private  patient  except  by  an  order  of 
the  attending  physician  of  the  hospital,  or  at  least  two  of  the  board  of 
trustees.  When  the  friends  of  such  person  supposed  to  be  insane  offer 
to  place  him  in  the  hospital  he  shall  not  be  admitted  until  the  trustees 
have  caused  inquiry  to  be  made  as  to  the  state  of  his  mind,  and  have 
found  him  to  be  insane.  A  sworn  certificate  of  insanity,  in  prescribed 
form,  from  at  least  one  respectable  physician,  must  be  produced,  setting 
forth  that  the  patient  is  free  from  any  infectious  disease,  and  giving  a 
concise  history  of  the  patient  and  his  disease. 

For  the  commitment  of  State  patients,  some  respectable  citizen  of  the 
county  where  the  patient  belongs  shall  file  with  a  justice  of  the  peace  a 
statement,  setting  forth  that  the  person  is  insane,  that  his  insanity  is  of 
less  than  two  years'  duration,  or  that  he  is  dangerous  to  be  at  large,  that 
he  is  in  needy  circumstances,  has  a  legal  settlement  in  the  county,  and 
is  a  citizen  of  Tennessee.  It  shall  also  give  the  names  of  two  persons, 
one  of  them  a  physician,  who  can  testify  to  the  facts  stated.  The  justice 
shall  summon  the  witnesses  named,  and  such  others  as  he  thinks  proper. 
If,  after  inquest,  the  justice  is  satisfied  of  the  truth  of  the  statement,  he 

1  Statutes  of  Tennessee,  1871,  Thompson  &  Steger,  Vol.  I.  pp.  767-781  ;  Vol.  II. 
pp.  1516-1521,  1700;  Vol.  III.  p.  271,  §  5488.  Acts  of  Tennessee,  1873,  pp.  74,  75, 
97 ;  1877,  p.  71 ;  1883,  p.  195. 


APPENDIX — TENNESSEE.  521 

shall  require  the  medical  witnesses  to  make  a  certificate,  such  as  is  required 
in  the  case  of  a  pay  patient,  in  regard  to  history,  condition,  etc.  The 
justice  shall  also  make  a  certificate,  stating  that  he  has  examined  the 
patient  and  finds  him  insane  and  poor,  and  a  fit  subject  for  the  hospital. 
A  certificate  of  the  facts  shall  be  filed  by  the  justice  with  the  clerk  of 
the  county  court.  The  clerk  shall  send  a  copy  to  the  superintendent  of 
the  hospital  and  make  application  for  the  patient's  commitment.  If  the 
superintendent  says  that  he  can  be  received,  the  clerk  shall  issue  a 
warrant  directing  that  the  patient  be  conveyed  to  the  hospital. 

Both  the  county  courts  and  the  chancery  courts  have  jurisdiction  to 
order  an  inquisition  to  be  made  into  the  sanity  of  any  person,  and  to 
appoint  a  guardian  for  his  person  and  property,  if  he  is  found  insane. 
If  a  person  so  found  to  be  an  idiot  or  lunatic  has  no  property,  or  not 
sufficient  for  his  maintenance,  he  may  be  let  out  for  the  term  of  one  year 
to  the  lowest  bidder  as  other  poor  persons,  or  otherwise  provided  for  as 
the  court  may  direct.  Security  is  to  be  taken  by  the  court  for  the  proper 
treatment  of  such  person.  Any  justice  of  the  peace  in  the  recess  of 
court,  if  satisfied  from  the  finding  of  a  jury,  or  otherwise,  that  there  is 
danger  of  violence  by  such  idiot  or  lunatic,  may  commit  him  to  jail  until 
the  next  term  of  the  court. 

When  the  plea  of  present  insanity  is  urged  in  behalf  of  any  person 
charged  with  a  criminal  offence,  punishable  with  imprisonment  or  death, 
and  the  jury  find  the  defendant  to  be  insane,  and  unsafe  to  be  set  at 
liberty,  the  court  shall  order  the  superintendent  of  the  Hospital  for  the 
Insane  to  receive  and  keep  the  defendant  as  other  lunatics  are  kept. 
When,  in  the  opinion  of  the  trustees  and  physician,  such  patient  has  re- 
covered from  his  insanity,  they  shall  cause  him  to  be  delivered  to  the 
jailer  of  Davidson  County  for  safe  keeping,  and  shall  send  notice  to  the 
clerk  of  the  county  where  the  patient  was  arraigned.  If,  at  the  next 
term  of  the  court,  the  district  attorney  wishes  further  to  prosecute  such 
person,  he  shall  be  taken  to  the  county  jail ;  but,  if  the  district  attorney 
does  not  wish  further  to  prosecute  the  prisoner,  he  shall  be  discharged. 

Whenever  the  physician  of  the  penitentiary  reports  to  the  keeper  that 
any  convict  is  insane  and  ought,  on  that  account,  to  be  removed  to  the 
lunatic  asylum,  the  keeper  shall  cause  such  insane  convict  to  be  so  re- 
moved, to  remain  in  the  hospital  until  discharged  by  the  physician  of  the 
lunatic  asylum. 

The  trustees  of  the  Hospital  for  the  Insane  have  power  to  discharge 
at  any  time  any  of  the  patients  in  the  hospital,  unless  committed  to 
custody  in  the  same  by  some  court. 

No  persons  not  citizens  of  the  State  shall  be  admitted  as  patients  in 
the  Hospital  for  the  Insane. 


522  APPENDIX  —  TEXAS. 


TEXAS.* 


The  following  persons  may  be  admitted  into  the  asylum  as  patients : 

1.  All  persons  who  have  been  adjudged  insane  by  a  court  of  competent 
jui'isdiction  in  this  State  and  ordered  to  be  conveyed  to  the  asylum.  This 
class  shall  be  known  as  public  patients. 

2.  All  persons  who  may  be  certified  to  be  insane  by  some  respectable 
physician,  under  the  regulations  hereafter  stated.  This  class  shall  be 
known  as  private  patients. 

Before  any  person  can  be  admitted  as  a  private  patient  the  parent  or 
legal  guardian  of  such  person,  or,  in  case  he  has  no  parent  or  legal 
guardian,  some  near  relative  or  other  person  interested  in  him,  must 
present  a  written  request  to  the  superintendent  for  his  admission,  setting 
forth  the  name,  age,  and  residence  of  the  lunatic,  with  such  other  par- 
ticulars as  may  be  required.  This  request  must  be  under  oath  and  ac- 
companied with  the  affidavit  of  the  physician  certifying  to  the  insanity 
that  he  h^s  made  careful  examination  of  the  person  and  verily  believes 
him  to  be  insane.  There  must  also  be  a  certificate  from  the  county  judge 
of  the  county  where  the  lunatic  resides,  that  the  examining  physician  is 
a  respectable  physician  in  regular  practice. 

All  private  patients  shall  be  kept  at  their  own  expense,  or  the  expense 
of  their  relatives  or  friends. 

All  public  patients  shall  be  kept  at  the  expense  of  the  State,  but  money 
so  paid  may  be  collected  from  the  patient  or  those  liable  for  his  support, 
if  they  have  property. 

If  applications  be  made  for  the  admission  of  more  patients  than  can  be 
accommodated  in  the  asylum,  preference  shall  be  given,  in  all  instances, 
to  public  over  private  patients,  and  of  the  former  class  to  cases  of  less 
than  one  year's  duration  over  chronic  cases,  and  to  indigent  patients  over 
those  possessed  of  property  ;  and  no  private  patients  shall  be  admitted 
during  the  pendency  of  an  application  by  a  public  patient,  nor  shall  any 
public  non-indigent  patient  be  admitted  during  the  pendency  of  an  appli- 
cation by  an  indigent  public  patient. 

No  idiot  who  can  be  safely  kept  in  the  county  to  which  he  belongs, 
nor  any  person  with  an  infectious  or  contagious  disease,  shall  be  received 
into  the  asylum  as  a  patient. 

Any  patient  (except  such  as  are  charged  with,  or  convicted  of,  some 
offence  and  have  been  adjudged  insane  in  accordance  with  the  provisions 
of  the  Code  of  Criminal  Procedure)  may  be  discharged  from  the  asylum 
at  any  time  upon  the  recommendation  of  the  superintendent,  approved 
by  the  board  of  managers.  Any  patient  coming  within  the  above  ex- 
ception can  only  be  discharged  by  order  of  the  court  by  which  he  was 
committed. 

No  patient  shall  be  discharged  without  suitable  clothing,  and  money 

>  Revised  Statutes  of  Texas,  1879,  pp.  20-26,  386,  387.  Penal  Code  [bound  with 
Revised  Statutes],  p.  5.  Code  of  Criminal  Procedure  [bound  with  Revised  Statutes], 
pp.  66,  86,  112,  113.     General  Laws  of  Texas,  1883,  pp.  9-11,  103-105. 


APPENDIX  —  TEXAS.  523 

sufficient  to  pay  his  expenses  home.  If  discharged  uncured,  he  shall  be 
conveyed,  under  guard,  to  his  friends,  or  to  the  county  from  which  he 
was  sent. 

If  information  in  writing,  under  oath,  be  given  to  any  county  judge 
that  any  person  in  his  county  is  a  lunatic  and  ought  to  be  placed  under 
restraint,  he  shall,  if  he  believes  the  statement,  forthwith  issue  h*s  warrant 
for  the  apprehension  of  such  person,  and  shall  fix  a  day  for  a  hearing  in 
the  matter.  He  shall  also  have  a  jury  of  six  competent  persons  of  the 
county  summoned  to  hear  and  determine  the  matter.  The  county 
attorney  shall  appear  and  represent  the  State,  and  the  defendant  shall  be 
entitled  to  counsel,  and  in  proper  cases  the  court  may  appoint  counsel 
for  him.  After  the  evidence  is  heard,  the  county  judge  shall  submit  the 
matter  to  the  jury.  Upon  return  of  a  verdict  finding  that  the  defendant 
is  of  usound  mind,  and  that  it  is  necessary  that  he  be  placed  under 
restraint,  judgment  shall  be  entered  adjudging  him  to  be  a  lunatic  and 
ordering  him  to  be  conveyed  to  the  lunatic  asylum  for  restraint  and 
treatment. 

Immediately  after  any  person  is  adjudged  a  lunatic  the  county  judge 
shall  communicate  with  the  superintendent  of  the  asylum,  and,  if  notified 
that  the  patient  can  be  accommodated,  he  shall  issue  his  warrant  to  have 
the  lunatic  conveyed  to  the  asylum  without  delay.  No  lunatic  shall  be 
taken  to  the  asylum  if  some  relative  or  friend  will  undertake,  before  the 
county  judge,  his  care  and  restraint,  giving  a  sufficient  bond  therefor. 

The  proceedings  in  any  inquisition  of  lunacy  shall  be  entered  of  record 
in  the  county  court,  and  a  transcript  made  of  the  same  and  sent  to  the 
superintendent  of  the  asylum  when  the  patient  is  sent  there.  The  county 
judge  shall  see  that  the  patient  is  supplied  with  proper  clothing  before 
sending  him  to  the  asylum. 

No  act  done  in  a  state  of  insanity  can  be  punished  as  an  offence.  No 
person  who  becomes  insane  after  he  committed  an  offence  shall  be  tried 
for  the  same  while  in  such  condition.  No  person  who  becomes  insane 
after  he  is  found  guilty  shall  be  punished  for  the  offence  while  in  such 
condition. 

Where  the  jury  are  of  opinion  that  a  person  pleading  guilty  is  insane, 
they  shall  so  report  to  the  court,  and  an  issue  as  to  that  fact  shall  be 
tried  before  another  jury.  If  upon  such  trial  it  be  found  that  the  de- 
fendant is  insane,  he  shall  be  committed  to  the  asylum  in  the  same 
manner  as  where  a  defendant  is  found  insane  after  conviction. 

If  it  be  made  known  to  the  court  at  any  time  after  conviction,  or  if 
the  court  has  good  reason  to  believe,  that  a  defendant  is  insane,  a  jury 
shall  be  impanelled  to  try  the  issue.  If  the  defendant  has  no  counsel, 
the  court  shall  appoint  counsel  for  him.  When  a  defendant  is  found  by 
the  jury  to  be  insane,  the  court  shall  make  an  order  committing  the  de- 
fendant to  the  custody  of  the  sheriff.  The  proceedings  shall  then  forth- 
with be  certified  to  the  county  judge,  who  shall  take  the  necessary  steps 
at  once  to  have  the  defendant  confined  in  the  lunatic  asylum  until  he 
becomes  sane.  Should  the  defendant  become  sane,  he  shall  be  brought 
before  the  court  in  Avhich  he  was  convicted,  and  a  jury  shall  again  be 
impanelled  to  try  the  issue  of  his  sanity  ;  and  should  he  be  found  to  be 
sane,  the  conviction  shall  be  enforced  against  him  in  the  same  manner  as 


524  APPENDIX  —  UTAH. 

if  the  proceedings  had  never  been  suspended ;  if  found  insane,  he  shall  be 
remanded  to  the  lunatic  asylum. 

The  judge  of  the  county  court  may,  on  proper  information  and  pro- 
ceedings, appoint  a  guardian  for  any  person  of  unsound  mind. 

If  any  person  shall  be  furiously  mad  or  so  far  disordered  in  his  mind  as 
to  endanger  his  own  person  or  the  property  of  others,  it  shall  be  the  duty 
of  the  guardian  or  other  person,  under  "vvhose  care  he  may  be,  to  confine 
him  in  some  suitable  place  until  the  first  regular  term  of  the  county 
court  of  his  county,  when  the  court  shall  make  such  order  for  the  restraint, 
support,  and  safe  keeping  of  such  person  as  the  circumstances  may  re- 
quire. If  the  persons  having  charge  of  such  an  insane  person  do  not 
confine  him,  or  if  there  be  no  one  in  charge  of  him,  any  magistrate  may 
cause  him  to  be  apprehended,  and  may  employ  any  person  to  confine  him 
in  some  suitable  place  until  the  county  court  makes  further  order  in  regard 
to  him. 


UTAH.^    (Territory.) 

Patients  may  be  admitted  to  the  asylum  in  the  following  manner :  The 
probate  judge  of  any  county  shall,  upon  application,  under  oath,  setting 
forth  that  a  person,  by  reason  of  insanity,  is  dangerous  to  be  at  large, 
cause  such  person  to  be  brought  before  him,  and  shall  summon  to  appear 
at  the  same  time  two  or  more  witnesses  who  well  knew  the  person  alleged 
to  be  insane,  who  shall  testify  as  to  his  conversation,  manners,  and  gen- 
eral conduct ;  and  the  judge  shall  also  cause  to  appear,  at  the  same  time, 
two  practising  physicians,  who  shall  be  present  during  the  hearing.  If, 
after  a  hearing  of  the  evidence,  and  a  personal  examination  of  the  alleged 
insane  person,  the  physicians  shall  certify  that  the  person  is  insane,  and 
the  case  is  of  a  recent  or  curable  character,  or  that  the  insane  person  is 
of  a  homicidal,  suicidal,  or  incendiary  disposition,  or  that  from  any  other 
violent  symptoms  he  would  be  dangerous  to  be  at  large,  the  judge,  if  con- 
vinced that  the  facts  are  in  accordance  with  the  physicians'  certificate, 
shall  direct  the  sheriff  or  some  suitable  person  to  convey  to,  and  place  in 
charge  of  the  officers  of,  the  Territorial  Insane  Asylum  such  insane 
person.  The  physicians  shall  also  certify  to  the  name,  age,  nativity,  resi- 
dence, occupation,  length  of  time  in  the  Territory,  State  or  country  last 
lived  in,  previous  habits,  premonitory  symptoms,  apparent  cause  and  class 
of  insanity,  duration  of  the  disease  and  present  condition,  as  nearly  as 
may  be  ascertained  by  examination  and  inquiry.  A  copy  of  the  com- 
plaint, commitment,  and  physicians'  certificate  shall  be  sent  to  the  medi- 
cal superintendent  of  the  asylum. 

No  case  of  idiocy,  imbecility,  harmless  chronic  mental  unsoundness  or 
delirium  tremens  shall  be  committed  to  the  asylum.     If  any  persons  of 

»  Laws  of  Utah,  1878,  pp.  134,  135,  159-161 ;  1880,  pp.  57-65,  75;  1882,  p.  32. 


APPENDIX^UTAH.  525 

either  of  these  classes  are  unlawfully  placed  in  the  asylum,  the  superin- 
tendent may  discharge  them  and  return  them  to  the  county  from  Avhich 
they  were  committed. 

If  an  insane  person  committed  to  the  asylum  has  property,  the  judge 
shall  appoint  a  guardian  to  take  charge  of  the  same,  and  apply  it  to 
paying  the  expenses  of  the  insane  person  in  the  asylum. 

The  kindred  or  friends  of  an  inmate  of  the  asylum  may  receive 
such  inmate  therefrom,  upon  giving  satisftictory  evidence  that  they  are 
capable  and  suited  to  take  charge  of,  and  give  proper  care  to,  such  insane 
person,  and  exercise  proper  restraint  over  him.  If  the  evidence  satisfies 
the  judge  on  these  points,  he  may  make  an  order,  directed  to  the  medical 
superintendent  of  the  asylum,  for  the  removal  of  such  person.  If,  after 
such  removal,  the  insane  person  is  not  properly  cared  for  or  restrained, 
the  judge  may  order  him  to  be  returned  to  the  asylum. 

Non-residents  of  the  Territory  shall  not  be  committed  to,  nor  supported 
in,  the  asylum,  except  temporarily,  until  they  can  be  returned  to  their 
home  or  friends. 

Indigent  patients  shall  be  supported  in  the  asylum  by  the  county  from 
which  they  are  sent. 

A  person  cannot  be  tried,  adjudged  to  punishment,  or  punished  for  a 
public  offence  while  he  is  insane.  When  an  indictment  is  called  for  trial, 
if  a  doubt  arises  as  to  the  sanity  of  the  defendant,  the  court  must  order 
the  question  to  be  submitted  to  a  jury ;  when  such  doubt  arises  on  the 
defendant  being  brought  up  for  judgment  on  conviction,  the  court  must 
order  a  jury  to  be  summoned  from  the  list  of  jurors  provided  by  law  to 
inquire  into  the  fact,  and  the  trial  of  the  indictment,  or  the  pronouncing 
of  the  judgment,  must  be  suspended  until  the  question  of  insanity  is 
determined  by  the  verdict  of  the  jury.  If  the  jury  find  the  defendant 
insane,  the  trial  or  judgment  must  be  suspended  until  he  becomes  sane, 
and  the  court,  if  it  deems  his  discharge  dangerous  to  the  public  peace  or 
safety,  may  order  that  he  be  in  the  mean  time  committed  by  the  proper 
officer  to  a  lunatic  asylum.  If  the  defendant  is  received  into  an  asylum, 
he  must  be  detained  there  until  he  becomes  sane,  when  he  must  be  brought 
from  the  asylum  and  placed  in  proper  custody  until  he  is  brought  to  trial 
or  judgment,  as  the  case  may  be,  or  is  legally  discharged. 

If,  after  judgment  of  death,  there  is  good  reason  to  suppose  that  the 
defendant  has  become  insane,  the  proper  officer,  with  the  concurrence  of 
the  judge  of  the  court  by  which  the  judgment  was  rendered,  may  sum- 
mon from  the  list  of  jurors  selected  by  the  proper  officers  for  the  year  a 
jury  of  twelve  persons  to  inquire  into  the  supposed  insanity.  The  prose- 
cuting attorney  must  attend  the  inquisition,  and  may  produce  witnesses. 
If  it  is  found  by  the  inquisition  that  the  defendant  is  insane,  the  officer 
must  suspend  the  execution  of  the  judgment  until  he  receives  a  warrant 
from  the  Governor,  or  from  the  judge  of  the  court  by  which  the  judg- 
ment was  rendered,  directing  the  execution.  The  Governor,  when  the 
defendant  becomes  sane,  may  appoint  a  day  for  the  execution  of  the 
judgment. 


526  APPENDIX — VERMONT. 


VERMONT.' 

No  person  shall  be  admitted  to,  or  detained  in,  an  insane  asylum  as  a 
patient  or  inmate,  except  upon  the  certificate  of  such  person's  insanity, 
stating  the  reasons  for  adjudging  such  person  insane,  made  by  two 
physicians  of  unquestioned  integrity  and  skill,  residing  in  the  probate 
district  in  which  such  insane  person  resides,  or,  if  such  insane  person  is 
not  a  resident  of  the  State,  in  the  probate  district  in  which  the  asylum 
is  situated ;  or  if  such  insane  person  is  a  convict  in  the  State  Prison  or 
House  of  Correction,  such  physicians  may  be  residents  of  the  probate 
district  in  which  such  place  of  confinement  is  situated.  The  two 
physicians  making  such  certificate  shall  not  be  members  of  the  same 
firm  and  neither  shall  be  an  officer  of  an  insane  asylum  of  this  State. 

The  next  friend  or  relative  of  a  person  thus  found  insane,  may  appeal 
to  the  supervisors  of  the  insane.  The  supervisors  shall  exp.mine  the  case, 
the  examination  being  had  in  the  town  where  the  appellant  resides. 
Pending  the  appeal,  the  patient  shall  not  be  committed  to  the  asylum. 
If  the  supervisors  find  that  there  was  not  sufficient  ground  for  making 
the  certificate,  they  shall  declare  it  void. 

Idiots  and  persons  non  compos,  who  are  not  dangerous,  shall  not 
be  confined  in  an  asylum  for  the  insane,  and,  if  any  such  persons  are  go 
confined,  the  supervisors  of  the  insane  shall  cause  them  to  be  discharged. 

The  physicians'  certificate,  above  mentioned,  shall  be  made  not  more 
than  ten  days  previous  to  the  admission  of  such  insane  person  to  the 
asylum  and  not  more  than  five  days  after  making  a  careful  examination. 
There  must  be  a  certificate  of  the  judge  of  probate  of  the  district  in 
which  the  physicians  reside,  that  the  physicians  are  of  unquestioned 
integrity  and  skill  in  their  profession.  This  certificate  shall  be  presented 
to  the  proper  ofiicer  of  the  asylum  at  the  time  the  patient  is  presented  for 
admission. 

Any  physician  signing  a  certificate  without  first  making  a  careful  exami- 
nation of  the  supposed  insane  person,  shall  be  liable  to  a  penalty  of  from 
$50  to  $100,  in  case  the  person  is  sent  to  an  asylum  on  such  certificate. 

A  person  may  be  received  into  an  asylum  without  a  certificate,  by  the 
order  or  sentence  of  the  supreme  or  county  court,  upon  the  presentation 
of  a  certified  copy  of  the  order  or  sentence. 

If  the  probate  judge,  in  a  case  duly  brought  before  him  by  the  select- 
men of  a  town  and  the  State's  attorney,  finds  that  an  insane  person  is 
without  a  settlement  in  any  town  and  is  liable  to  be  supported  by  the 
State,  and  the  insanity  of  such  person  is  certified  to  by  two  physicians  of 
unquestioned  skill  and  integrity,  resident  in  said  probate  district,  who  are 
duly  indorsed  by  said  judge,  the  judge  shall  issue  an  order  for  the 
removal  of  such  insane  person  to  the  Vermont  Asylum  for  the  Insane,  to 
be  there  supported.  The  oflScer,  or  other  person  appointed  by  the  judge 
to  transport  such  insane  person  to  the  asylum,  shall  leave  with  the  super- 

'  Revised  Laws  of  Vermont,  1880,  pp.  355,  491,  559-565,  813,  844.  Laws  of  Ver- 
mont, 1882,  pp.  55-59. 


APPENDIX  —  VERMONT.  527 

intendent,  or  one  of  the  trustees  of  the  asylum,  a  copy  of  the  judge's 
order  and  also  a  copy  of  the  physicians'  certificate  indorsed  by  the  judge. 
When  such  person  is  lawfully  discharged  from  the  asylum,  the  town 
causing  him  to  be  removed  thereto  shall  take  charge  of  and  support  him 
again. 

No  patient  shall  be  supported  in  the  asylum  entirely  at  the  expense  of 
the  State  unless  he  is  sent  there  upon  the  order  of  a  probate  judge,  or 
from  the  State  Prison  or  House  of  Correction,  or  upon  the  order  or  sen- 
tence of  the  county  or  supreme  court.  Insane  town  paupers  or  insane 
persons  in  indigent  circumstances  shall  be  supported  by  the  town  where 
they  belong,  at  the  Vermont  Asylum  for  the  Insane.  The  selectmen 
may  make  contracts  with  the  officers  of  the  asylum  for  their  support.  If 
a  person  is  insane  and  his  property  is  not  sufficient  to  support  himself 
and  his  wife  and  children,  his  wife  may  complain  to  the  county  court  in 
the  county  where  such  insane  person  has  his  settlement,  and  the  court, 
after  a  hearing,  may  order  the  town  to  support  the  insane  person  at  the 
asylum.  In  certain  cases  the  State  will  pay  a  part  of  the  expenses 
of  poor  patients  placed  in  the  hospital  by  the  selectmen  of  a  town. 

There  shall  be  three  supervisors  of  the  insane  elected  by  the  general 
assembly,  two  of  whom  shall  be  physicians,  and  none  of  them  shall  be  a 
trustee  or  officer  of  an  insane  asylum  in  the  State.  The  supervisors 
shall  visit  every  asylum  for  the  insane  in  the  State,  one  of  the  board  as 
often  as  once  a  month,  and  they  shall  examine  into  the  management 
and  condition  of  the  patients,  and  they  shall  particularly  ascertain 
whether  persons  are  confined  in  any  asylum  who  ought  to  be  discharged, 
and  they  may  make  such  orders  as  any  case  requires.  The  supervisors 
may  discharge,  by  their  order  in  writing,  any  person  confined  as  a  patient 
in  any  asylum  for  the  insane  whom  they  find,  on  investigation,  to  be 
wrongfully  confined,  or  whom  they  find  so  far  sane  as  to  warrant  dis- 
charge. But  convicts  sent  to  the  asylum  from  the  State  Prison  or 
House  of  Correction,  who  are  found  insane  before  the  expiration  of  their 
sentence,  shall  not  be  discharged,  but  shall  be  returned  to  the  prison  or 
house  of  correction.  In  no  case  shall  the  supervisors  order  the  discharge 
of  a  patient  without  giving  the  superintendent  of  the  asylum  an 
opportunity  to  be  heard. 

The  Governor  may  refer  the  case  of  any  patient  in  the  asylums  for  the 
insane  to  the  supervisors  for  their  investigation.  If  in  any  case  they 
have  not  the  power  to  grant  the  necessary  relief,  they  shall,  if  the  patient 
is  one  of  the  insane  poor  of  the  State,  cause  such  proceedings  to  be  com- 
menced in  court  as  are  necessary  to  obtain  the  required  relief. 

The  friends  or  relatives  of  a  patient  may  apply  to  the  supervisors 
to  inquire  into  the  treatment  and  confinement  of  such  patient,  and  the 
supervisors  shall  take  such  action  upon  such  application  as  it  requires. 

If  a  trustee,  superintendent,  employe,  or  other  officer  of  an  asylum 
for  the  insane  wilfully  and  knowingly  neglects  or  refuses  to  discharge  a 
patient  after  such  patient  has  become  sane,  or  after  the  supervisors  have 
.ordered  his  discharge,  he  shall  be  fined  not  more  than  $500. 

It  shall  be  the  duty  of  the  legal  guardian  of  any  insane  person  not  a 
pauper,  and  the  duty  of  the  overseer  of  the  poor  of  the  town  in  which 
any  insane  person  who  is  a  pauper  resides,  when  such  insane  person 


528  APPENDIX — VERMONT. 

is  not  placed  in  an  asylum,  to  keep  such  insane  person  under  such 
restraint  as  may  be  necessary  to  prevent  his  going  at  large.  If  any 
insane  person,  not  a  pauper,  found  going  at  large  in  any  town,  shall  have 
no  legally  appointed  guardian,  application  for  the  appointment  of  a 
guardian  over  him  may  be  made  to  the  probate  court  of  the  district  in 
which  such  insane  person  resides  by  the  selectmen  of  the  town  where 
such  insane  person  is  going  at  large. 

When  a  person  held  in  prison  on  a  charge  of  having  committed  an 
offence  is  not  indicted  by  the  grand  jury  by  reason  of  insanity,  the  grand 
jury  shall  so  certify  to  the  court,  and  thereupon  if  the  discharge  or  going 
at  large  of  such  insane  person  is  deemed  manifestly  dangerous  to  the 
community,  the  court  may  order  him  confined  in  the  county  jail  or  in 
the  insane  asylum  at  Brattleboro  or  some  other  suitable  place  at  his 
own  expense  if  he  has  estate  sufficient  for  the  purpose,  and,  if  not,  at  the 
expense  of  the  State. 

When  a  person  tried  on  an  indictment  or  information  for  any  crime  or 
offence  is  acquitted  by  the  jury  by  reason  of  insanity,  the  jury,  in  giving 
their  verdict  of  not  guilty,  shall  state  that  it  is  given  for  such  cause,  and 
thereupon,  if  the  discharge  or  going  at  large  of  such  insane  person 
is  considered  dangerous,  the  court  may  order  him,  in  its  discretion,  to  be 
confined  in  the  State  Prison  or  in  the  insane  asylum  at  Brattleboro,  on 
such  terms  as  the  court  directs. 

A  person  confined  as  insane  under  an  order  of  court,  after  having  been 
acquitted  or  not  indicted  because  of  his  insanity,  shall  be  discharged 
from  confinement  only  by  order  of  the  county  court  for  the  county 
in  which  the  order  for  confinement  was  made,  upon  petition  therefor,  and 
after  notice  to  the  State's  attorney. 

In  case  such  person  is  confined  in  the  insane  asylum  at  Brattleboro, 
and  has  no  estate,  such  petition  may  be  brought  in  his  behalf  by  the 
supervisors  of  the  insane  at  the  expense  of  the  State.  The  court  thus 
petitioned  may  direct  that  such  insane  person  be  brought  before  it  for 
hearing.  If,  upon  hearing,  it  appears  to  the  court  that  such  person  has 
become  sane,  and  his  discharge  or  going  at  large  is  not  considered  by  the 
court  dangerous  to  the  community,  the  court  shall  order  the  discharge  of 
such  person  from  confinement.  Otherwise  the  petition  shall  be  dismissed 
and  such  person  shall  be  recommitted  to  the  place  of  confinement  from 
which  he  was  brought. 

When  a  person  acquitted  of  any  crime  or  offence  because  of  his 
insanity  is  confined  by  order  of  the  court,  such  court  may,  on  petition 
and  after  notice  to  the  State's  attorney,  alter  the  terms  on  which  such 
person  is  confined. 

When  a  person  confined  in  the  house  of  correction  or  State  Prison  for 
a  specified  time,  or  for  life,  becomes  insane,  and  proper  certificates  of  that 
fact  are  made,  the  directors  may  cause  such  prisoner  to  be  removed  to  the 
insane  asylum  at  Brattleboro,  on  such  terms  as  they  deem  just,  there  to 
remain  until  he  becomes  cured  of  his  insanity,  or  until  the  expiration  of 
the  term  for  which  he  was  committed  to  the  prison  or  house  of  correction. 

If  before  the  expiration  of  such  term  such  person  becomes  sane,  he 
shall  be  returned  to  the  institution  to  which  he  was  originally  committed, 
and  confined  therein  for  the  remainder  of  said  term.     A  prisoner,  who  at 


APPENDIX  — VIRGINIA.  529 

the  expiration  of  his  term  of  confinement  remains  insane,  may  be  removed 
to  the  insane  asylum  at  Brattleboro,  and  may  be  there  kept,  or,  if  already 
there,  may  remain  at  the  expense  of  the  State  or  of  the  town  where 
he  belongs,  or  of  the  relatives  bound  to  support  him. 


VIRGINIA. 


On  an  application  on  behalf  of  a  person  for  his  admission  into  an 
asylum,  the  examining  board  (directors  of  the  asylum),  if  unanimous 
that  he  ought  to  be  admitted,  may  receive  him  as  a  patient  therein,  pro- 
vided sufficient  security  is  given  for  the  payment  of  the  patient's  ex- 
penses, and  his  removal  when  required. 

Any  justice  who  shall  suspect  any  person  in  his  county  or  corporation 
to  be  a  lunatic  shall  have  such  person  brought  before  him.  He  and  two 
other  justices  shall  inquire  whether  such  person  be  a  lunatic,  and,  for 
that  purpose,  summon  his  physician,  if  any,  and  any  other  witnesses. 
They  shall,  so  far  as  the  same  are  applicable,  propound  sixteen  prescribed 
questions  relating  to  the  history  and  condition  of  the  patient.  If  the 
said  justices  decide  that  the  person  is  a  lunatic,  and  ought  to  be  confined, 
and  ascertain  that  he  is  a  citizen  of  the  State,  then,  unless  some  person 
will  give  bond,  Avith  sufficient  security,  to  restrain  and  take  proper  care 
of  such  lunatic,  the  justices  shall  order  him  to  be  taken  to  the  nearest 
asylum,  if  there  be  room  therein,  and,  if  not,  to  the  other.  The  written 
interrogatories  and  answers,  and  a  written  statement  by  the  justices  as  to 
the  fact  of  insanity,  shall  be  sent  with  their  order  to  the  asylum.  The 
sheriff  or  officer  who  is  to  execute  the  order  of  the  justices  shall  ascertain 
whether  there  is  a  vacancy  in  the  nearest  asylum,  and,  if  there  be  none, 
he  shall  make  inquiry  of  the  other  superintendents.  Until  it  is  ascer- 
tained that  there  is  a  vacancy,  the  patient  shall  be  kept  in  the  jail  of 
the  county  or  corporation.  When  such  patient  arrives  at  the  asylum,  the 
board  of  directors  shall  be  assembled,  as  soon  as  may  be,  and,  if  they 
concur  in  opinion  with  the  justices,  they  shall  receive  and  register  him  as 
a  patient.  If  they  refuse  to  receive  the  lunatic,  the  officer  in  whose  cus- 
tody he  may  be  shall  confine  him  in  the  jail  of  the  county  where  he  was 
examined  until  lawfully  discharged  or  removed  therefrom.  If  a  person 
found  insane  is  not  sent  to  an  asylum,  he  shall  be  placed  in  the  hands  of 
a  committee  of  the  person  and  estate. 

If  a  lunatic  who  is  committed  to  jail,  or  received  into  an  asylum,  is 
found  to  be  a  non-resident  of  the  State,  he  shall,  as  soon  as  practicable, 
be  returned  to  his  friends  or  to  the  proper  authorities  of  the  State  where 

1  Code  of  Virginia,  1873,  pp.  714-725,  1241,  1247,  1248.  Acts  of  Assembly,  Vir- 
ginia, 1874,  pp.  23,  24;  1875-76,  p.  8;  1876-77,  pp.  38,  39;  1877-78,  pp.  215,  216; 
1878-79,  pp.  867,  368;  1881-82,  pp   134,  135. 

34 


530  APPENDIX — VIRGINIA. 

he  belongs.  No  non-resident  lunatic  shall  be  admitted  or  retained  in 
either  asylum  as  a  pay  patient,  except  ^vhen  there  is  a  vacancy  not  applied 
for  on  behalf  of  any  person  residing  in  the  State. 

The  Governor  is  authorized  to  cause  insane  persons  not  now  kept  in 
either  of  the  State  lunatic  asylums  to  be  taken  to  and  kept  in  such  insane 
asylums  beyond  the  limits  of  the  State  as  he  may  select,  and  he  may  make 
all  necessary  arrangements  with  the  pei^sons  having  charge  of  such  asylums. 

Insane  persons  of  the  naval  service  of  the  United  States  who  may  be 
sent  to  either  asylum  by  the  Secretary  of  the  Navy  may  be  received  so 
long  as  there  is  room  in  the  asylums,  but  when  it  shall  become  necessary 
for  the  purpose  of  accommodating  insane  persons  who  are  citizens  of  the 
State,  such  insane  persons  of  the  naval  service,  or  so  many  as  may  be 
necessary,  shall  be  removed  from  the  asylums  and  restored  to  the  care  of 
the  Secretary  of  the  Navy. 

Idiots  may  not  be  sent  to,  or  kept  in,  the  insane  asylums,  but  shall  be 
taken  charge  of  by  their  committees  or  by  the  overseers  of  the  poor. 

Except  in  the  case  of  patients  charged  with  crime,  the  board  of  any 
asylum,  or  the  court  of  any  county  or  corporation,  may  deliver  any  lunatic 
confined  in  such  asylum,  or  in  the  jail  of  the  county,  to  any  friend  who 
will  give  proper  bond  to  take  care  of  him,  and  where  any  lunatic  not  a 
criminal  is  deemed  by  the  superintendent  of  any  asylum  both  harmless 
and  incurable,  the  board  may  deliver  him,  without  any  bond,  to  any 
friend  who  is  willing  and  able  to  take  care  of  him. 

If  any  person  who  has  given  bond  and  taken  charge  of  a  lunatic  wishes 
to  be  relieved  of  the  care  of  him,  he  may  deliver  him  to  the  sheriflF  of  the 
county,  or  sergeant  of  the  corporation,  according  to  the  condition  of  the 
bond.  Such  sheriff  or  sergeant  shall  carry  the  lunatic  before  a  justice  of 
his  county  or  corporation,  and  the  regular  proceedings  shall  be  had  for 
committing  the  patient  to  an  asylum. 

If  a  person  who  has  given  bond  to  take  care  of  a  lunatic  desires  to  put 
him  in  an  asylum,  he  may  take  the  patient  directly  before  a  justice,  and 
may  perform  all  the  duties  that  a  sheriff  or  sergeant  might  perform  in 
the  matter  of  having  him  committed  to  the  asylum. 

When  a  person  in  jail  on  a  charge  of  having  committed  a  criminal 
offence  appears,  from  a  certificate  of  a  grand  jury,  or  otherwise,  to  the 
satisfaction  of  the  court  in  which  he  is  held  to  answer,  to  have  been 
insane  at  the  time  of  committing  the  act,  and  continues  to  be  so  insane, 
the  court,  in  its  discretion,  may  order  him  to  be  sent  to  one  of  the  lunatic 
asylums  of  the  State,  or  to  be  delivered  to  his  friends. 

If  a  court  in  which  a  person  is  held  for  trial  see  reasonable  ground  to 
doubt  his  sanity  at  the  time  of  trial,  it  shall  suspend  the  trial  and  impanel 
a  jury  to  inquire  into  the  insanity.  If  the  jury  find  that  the  accused  is 
insane,  they  shall  inquire  whether  or  not  he  was  so  at  the  time  of  the 
alleged  offence.  If  they  find  that  he  was  insane  at  that  time,  the  court 
may  dismiss  the  prosecution,  and  either  discharge  him  or,  to  prevent  his 
doing  mischief,  remand  him  to  jail  and  order  him  to  be  removed  thence 
to  one  of  the  lunatic  asylums.  If  they  find  that  he  was  not  insane  at  the 
time  the  offence  was  committed,  but  has  become  so  since,  the  court  shall 
commit  him  to  jail  or  order  him  to  be  confined  in  one  of  the  asylums 
until  he  is  so  restored  that  he  can  be  put  on  trial. 


APPENDIX  —  WASHINGTON.  531 

When  a  person  tried  for  an  offence  is  acquitted  by  the  jury  by  reason 
of  his  being  insane,  the  verdict  shall  state  the  fact,  and  thereupon  the 
court  may,  if  it  deems  him  dangerous,  order  him  to  be  committed  to  jail 
until  he  can  be  sent  to  one  of  the  asylums. 

If,  after  conviction  and  before  sentence  of  any  person,  the  court  see 
reasonable  ground  to  doubt  his  sanity,  it  may  impanel  a  jury  to  inquire 
into  the  fact  as  to  his  sanity,  and  sentence  him  or  commit  him  to  jail  or 
to  a  lunatic  asylum,  according  as  the  jury  may  find  him  to  be  insane  or 
sane. 

When  any  person  confined  in  an  asylum  and  charged  Avith  crime,  and 
subject  to  be  tried  therefor,  or  convicted  of  crime,  shall  be  restored  to 
sanity,  the  board  shall  give  notice  thereof  to  the  clerk  of  the  court  by 
whose  order,  or  by  the  order  of  the  judge  of  which  he  was  confined. 
Such  clerk  shall  issue  a  precept  requiring  the  prisoner  to  be  brought 
from  the  asylum  and  committed  to  jail.  When  a  prisoner  is  so  brought 
from  the  asylum  and  committed  to  jail,  or  when  it  is  found  by  the  verdict 
of  another  jury  that  a  prisoner  whose  ti'ial  or  sentence  was  suspended  by 
reason  of  his  being  found  to  be  insane  has  been  restored  to  reason,  if  he 
has  already  been  convicted,  he  shall  be  sentenced ;  if  not,  the  trial  shall 
be  held  as  if  no  delay  had  occurred  on  account  of  his  insanity. 

When  any  person  not  a  criminal,  confined  in  an  asylum  or  jail  as  a 
lunatic,  shall  be  restored  to  sanity,  the  board  or  the  court,  as  the  case  may 
be,  shall  discharge  him  and  give  him  a  certificate  thereof. 

When  any  person  shall  be  confined  in  any  jail  as  a  lunatic,  the  jailer 
shall  certify  the  fact  to  the  court  of  the  county  or  corporation  at  their 
next  term.  The  court  shall  thereupon  cause  such  person  to  be  examined 
by  two  disinterested  persons,  who  shall,  as  soon  as  may  be,  report  the 
result  thereof  The  court  shall  then  make  such  provision  for  the  main- 
tenance and  care  of  the  patient  as  his  condition  may  require.  It  shall, 
when  practicable  and  proper,  contract  with  some  fit  person  for  the  main- 
tenance and  care  of  such  lunatic  out  of  the  jail,  and  make  allowance  for 
the  expense  of  such  support  not  exceeding  what  is  authorized  for  a  lunatic 
confined  in  jail. 

The  committee  of  an  insane  person  appointed  by  the  circuit  or  county 
courts  shall  be  entitled  to  the  custody  and  control  of  his  person  when  he 
resides  in  the  State  and  is  not  confined  in  an  asylum  or  jail. 


WASHINGTON.^    (Territory.) 

No  person  laboring  under  any  contagious  or  infectious  disease  shall  be 
admitted  to  the  lunatic  hospital  as  patient.  In  admitting  patients  to,  and 
retaining  them  in,  the  hospital,  the  indigent  insane  of  the  Territory  shall 

1  Washington  Code  and  Appendix,  1881,  pp.  203,  204,  276-281,  351,  388-394. 


632  APPENDIX — WASHINGTON. 

have  precedence,  and  if  the  hospital  at  any  time  becomes  crowded,  recent 
cases  shall,  for  the  time  being,  have  precedence  over  those  of  a  chronic 
character. 

The  probate  court  of  any  county,  or  the  judge  thereof,  upon  applica- 
tion of  any  person,  under  oath,  setting  forth  that  any  person,  by  reason 
of  insanity,  is  unsafe  to  be  at  large,  or  is  suffering  under  mental  derange- 
ment, shall  cause  such  person  to  be  brought  before  said  court,  or  judge, 
at  a  time  appointed,  and  shall  cause  to  appear  at  the  same  time  one  or 
more  respectable  physicians,  who  shall  state,  under  oath,  in  writing,  their 
opinion  of  the  case.  If  the  physician  or  physicians  shall  certify  to  the 
insanity  or  idiocy  of  the  person,  and  it  appears  to  the  satisfaction  of  the 
court,  or  judge,  that  such  certificate  is  true,  said  court,  or  judge,  shall 
cause  such  insane  or  idiotic  person  to  be  taken  to  the  Hospital  for  the 
Insane  in  Washington  Territory ;  provided,  that  such  alleged  insane  per- 
son, or  any  person  in  his  behalf,  may  demand  a  jury  to  decide  upon  the 
question  of  his  insanity,  and  the  court,  or  judge,  shall  discharge  such 
person  if  the  verdict  of  the  jury  is  that  he  is  sane. 

The  probate  court,  or  judge,  shall  also  inquire  as  to  the  property  of 
such  insane  person,  and  in  case  such  person  shall  have  sufficient  means 
to  bear  such  expense,  two  months'  charges  shall  be  paid  in  advance  on 
his  admission,  and  a  like  amount  every  two  months  thereafter  so  long  as 
he  remains  in  the  hospital.  If  the  relations  or  friends  of  such  insane  or 
idiotic  person  desire  to  take  charge  of  him,  the  court,  or  judge,  may  so 
order,  if  sufficient  bond  is  given  that  such  insane  or  idiotic  person  shall 
be  well  and  securely  kept.  If  it  be  found  by  the  court  that  the  person 
so  brought  before  it  is  of  unsound  mind,  and  incapable  of  managing  his 
own  affiiirs,  and  has  property,  the  court  shall  appoint  a  guardian  for  the 
estate  of  such  insane  person. 

Paying  patients,  whose  friends  or  whose  property  can  pay  their  ex- 
penses, shall  do  so  in  accordance  with  the  contract  made  with  the  trustees 
of  the  hospital. 

Whenever  the  court  shall  receive  information  that  an  insane  person 
under  guardianship  has  recovered  his  reason,  it  shall  inquire  into  the 
facts,  and,  if  it  finds  that  such  person  is  of  sound  mind,  shall  forthwith 
discharge  him  from  care  and  custody. 

Any  patient  may  be  discharged  from  the  hospital,  when,  in  the  judg- 
ment of  the  superintendent,  it  may  be  expedient. 

Whenever  a  patient  not  cured,  or  any  indigent  patient,  shall  be  ordered 
discharged,  he  shall,  if  the  superintendent  thinks  fit,  be  sent  unattended 
to  the  county  where  he  belongs ;  but  if  for  any  reason  he  is  unfit  to  be 
sent  alone,  the  superintendent  shall  so  certify  to  the  probate  judge  of  said 
county,  who  shall  order  the  sheriff  to  remove  the  patient  to  the  county 
from  which  he  came.  No  pauper  shall  be  discharged  from  the  hospital 
without  suitable  clothing,  and  such  sum  of  money,  not  exceeding  $10, 
aS  the  trustees  deem  necessary. 

There  shall  be  no  censorship  exercised  over  the  correspondence  of  the 
inmates  of  insane  asylums,  except  as  to  the  letters  to  them  directed ;  but 
their  other  post-office  rights  shall  be  as  free  and  unrestrained  as  are  those 
of  any  other  resident  or  citizen  of  this  Territory,  and  be  under  the  pro- 
tection of  the  same  postal  laws ;  and  every  inmate  shall  be  allowed  to 


APPENDIX  —  WEST    VIRGINIA.  533 

write  one  letter  a  week  to  any  person  he  or  she  may  choose.  There  shall 
be  a  post-office  box  in  the  asylum. 

In  all  asylum  investigations,  the  testimony  of  any  person  offered  as  a 
witness,  whether  sane  or  insane,  shall  be  competent,  the  court  and  jury 
being  sole  judges  of  its  credibility. 

The  district  courts  of  the  Territory  shall  have  power  to  commit  to  the 
insane  hospital  any  person  who,  having  been  arraigned  for  an  indictable 
offence,  shall  be  found  by  the  jury  to  be  insane  at  the  time  of  such 
arraignment. 

When  any  person  indicted  for  an  offence  shall  on  trial  be  acquitted  by 
reason  of  insanity,  the  jury,  in  giving  their  verdict,  shall  so  state,  and 
thereupon,  if  the  discharge  or  going  at  large  of  such  insane  person  shall 
be  considered  by  the  court  manifestly  dangerous,  the  court  may  order 
him  to  be  committed  to  the  insane  asylum,  or  may  give  him  into  the  care 
of  his  friends,  if  they  will  give  sufficient  bonds  that  he  will  be  well  and 
securely  kept.     Otherwise  he  shall  be  discharged. 


WEST  VIRGINIA.^ 

Any  justice  who  shall  suspect  any  person  in  his  county  to  be  a  lunatic, 
shall  issue  his  warrant  and  have  the  person  brought  before  him.  He  shall 
make  inquiry  whether  such  person  is  a  lunatic,  and  for  that  purpose  sum- 
mon a  physician  and  other  witnesses.  He  shall  propound  so  many  of 
fifteen  prescribed  questions  as  are  applicable  to  the  case,  touching  the 
history  and  condition  of  the  patient.  If  the  justice  decide  that  the  per- 
son is  a  lunatic  and  ought  to  be  confined  in  the  hospital,  and  ascertain 
that  he  is  a  citizen  of  the  State,  then,  unless  some  person  will  give  suffi- 
cient security  to  restrain  and  take  proper  care  of  such  lunatic,  the  justice 
shall  order  him  to  be  removed  to  the  hospital.  The  interrogatories  and 
their  answers,  together  with  a  written  statement  by  the  justice  of  any 
facts  relating  to  the  insanity,  shall  be  sent  with  the  order  to  the  hospital. 
The  sheriff  or  other  officer  who  is  to  execute  the  order,  shall  make* 
inquiry  of  the  superintendent  whether  he  can  receive  the  lunatic  into  the 
hospital,  and  whether  he  will  send  for  the  patient  or  have  the  sheriff  take 
him  to  the  hospital.  Until  the  patient  can  be  received  in  the  hospital, 
he  shall  be  kept  in  the  jail  of  the  county.  When  such  patient  arrives  at 
the  hospital,  the  examining  board,  consisting  of  the  medical  superinten- 
dent and  one  or  more  directors,  shall  be  assembled  as  soon  as  may  be, 
and,  if  they  concur  in  opinion  with  the  justice,  the  patient  shall  be 
registered  as  an  inmate  upon  proper  security  for  payment  of  expenses. 
If  they  refuse  to  receive  the  lunatic,  the  officer  in  charge  of  him  shall 

1  Eevised  Statutes  of  West  Virginia,  Annotated,  187!),  Vol.  I.  pp.  440,  446,  447; 
Vol.  II.  pp.  673-680  Acts  of  West  Virginia,  1881,  p.  266;  1882,  pp.  133-137; 
1883,  pp.  55,  56. 


634  APPENDIX — WEST    VIRGINIA. 

confine  him  in  the  jail  of  the  county  in  which  he  was  examined  until 
lawfully  discharged  or  removed  therefrom. 

If  a  lunatic  is  found  to  be  a  non-resident,  he  shall  be  returne'd  to  his 
friends  or  to  the  proper  authorities  of  the  State  from  which  he  came,  and 
the  Governor  shall  collect  from  that  State,  if  possible,  the  money  expended 
for  such  patient. 

No  non-resident  lunatic  shall  be  received  or  retained  as  a  pay  patient 
in  the  hospital,  except  when  there  is  a  vacancy  not  applied  for  on  behalf 
of  any  person  residing  in  the  State. 

Insane  persons  of  the  naval  service  of  the  United  States,  who  may  be 
sent  to  the  hospital  by  the  Secretary  of  the  Navy,  may  be  received  and 
kept  so  long  as  there  is  room  not  wanted  for  citizens  of  the  State. 

Idiots  are  not  to  be  sent  to  or  received  into  the  hospital,  but  are  to  be 
taken  charge  of  by  their  committees  if  they  have  any,  if  not,  by  the 
supervisors  or  any  of  them. 

Except  in  case  of  insane  criminals,  the  board  of  the  hospital,  or  the 
circuit  court  of  any  county,  may  deliver  any  lunatic  confined  in  the  hos- 
pital, or  in  the  jail,  to  any  friend  who  will  give  sufficient  security  to 
restrain  and  properly  care  for  the  lunatic ;  and  where  a  lunatic,  not  a 
criminal,  is  deemed  by  the  superintendent  of  the  hospital  both  hanuless 
and  incurable,  the  board  may  deliver  him  without  any  bond  to  any  friend 
who  is  willing,  and,  in  the  opinion  of  the  board,  able  to  take  care  of  him. 

When  any  person  who  has  given  bond  and  taken  charge  of  a  lunatic 
wishes  to  be  relieved  of  the  care  of  him,  he  may  deliver  him  to  the 
sheriif  of  the  county  according  to  the  condition  of  the  bond.  The  sheriff 
shall  confine  such  patient  in  the  jail  of  his  county  until  a  vacancy  shall 
occur  in  the  hospital. 

When  any  person  shall  be  confined  in  any  jail  as  a  lunatic,  the  jailer 
shall  certify  the  fact  to  the  circuit  court  of  the  county  at  the  next  term. 
The  court  shall  cause  such  person  to  be  examined  by  two  disinterested 
persons,  who  shall,  as  soon  as  may  be,  report  the  result  thereof.  The 
court  shall  then  make  such  provision  for  his  maintenance  and  care  as  his 
situation  may  require.  The  court  in  whose  jail  any  lunatic  may  be  con- 
fined, shall,  when  practicable  and  proper,  contract  with  some  fit  person 
for  the  care  and  maintenance  of  such  lunatic  out  of  jail,  and  make  allow- 
ance therefor  not  exceeding  what  is  authorized  for  a  lunatic  confined 
in  jail. 

The  circuit  court  shall,  on  application  of  any  party  interested,  examine 
any  person  suspected  of  being  insane,  with  a  view  to  appointing  a  com- 
mittee. If  a  person  be  found  to  be  insane  by  the  justice  before  whom 
he  may  be  examined,  or  in  a  court  in  which  he  may  be  charged  with 
crime,  the  circuit  court  of  the  county  of  which  he  is  an  inhabitant  shall 
appoint  a  committee  of  him.  The  committee  of  an  insane  person 
shall  be  entitled  to  the  custody  and  control  of  his  person  when  he  resides 
in  the  State  and  is  not  confined  in  the  hospital  or  jail. 

When  any  person,  not  a  criminal,  confined  in  the  hospital  or  jail  as  a 
lunatic  shall  be  restored  to  sanity,  the  board  of  directors,  if  such  person 
be  in  the  asylum,  or,  if  confined  in  jail,  the  circuit  or  county  court,  or 
any  justice  of  the  county  in  which  such  person  is  confined,  upon  exami- 


APPENDIX  —  WISCONSIN.  535 

nation  of  such  person,  if  it  be  found  proper  to  do  so,  shall  discharge 
such  person  and  give  him  a  certificate  thereof. 

Wheh  a  person  in  jail,  on  a  charge  of  having  committed  an  indictable 
offence,  is  not  indicted  by  reason  of  his  insanity  at  the  time  of  commit- 
ting the  act  and  the  grand  jury  certify  this  fact,  the  court  may  order  him 
to  be  sent  to  the  hospital  for  the  insane  of  the  State,  or  to  be  discharged. 

If  a  court  in  which  a  person  is  indicted  for  a  criminal  offence  see  reason- 
able ground  to  doubt  his  sanity,  at  the  time  of  trial,  it  shall  suspend  the 
trial  and  impanel  a  jury  to  inquire  into  the  insanity.  If  the  jury  find 
that  he  is  then  insane,  they  shall  inquire  further  whether  he  was  so  at 
the  time  of  the  alleged  offence.  If  they  find  that  he  was  so  at  that  time, 
the  court  may  dismiss  the  prosecution  and  either  discharge  him  or,  to 
prevent  his  doing  mischief,  remand  him  to  jail  and  order  him  to  be 
removed  thence  to  the  hospital  for  the  insane.  If  they  find  that  he  was 
not  insane  at  the  time  of  the  alleged  offence,  but  has  since  become  so, 
the  court  shall  commit  him  to  jail,  or  order  him  to  be  confined  in  the 
hospital  until  he  is  so  restored  that  he  can  be  put  upon  his  trial. 

When  a  person  tried  for  an  offence  is  acquitted  by  the  jury  by  reason 
of  his  being  insane,  the  verdict  shall  state  the  fact,  and  thereupon  the 
court  may,  if  it  deem  him  dangerous,  order  him  to  be  committed  to  jail 
until  he  can  be  sent  to  the  hospital  for  the  insane. 

If,  after  conviction  and  before  sentence  of  any  person,  the  court  see 
reasonable  ground  to  doubt  his  sanity,  it  may  impanel  a  jury  to  inquire 
into  the  fact  as  to  his  sanity,  and  sentence  him  or  commit  him  to  jail  or 
to  the  hospital  for  the  insane,  according  as  the  jury  may  find  him  to  be 
sane  or  insane. 

When  any  person  confined  in  the  hospital  and  subject  to  be  tried  for 
crime,  or  convicted  of  crime  and  held  for  sentence,  shall  be  restored 
to  sanity,  the  board  shall  give  notice  thereof  to  the  clerk  of  the  court  by 
whose  order  he  was  confined.  Such  clerk  shall  issue  a  precept  requiring 
the  prisoner  to  be  brought  from  the  hospital  and  committed  to  jail.  When 
a  prisoner  is  so  brought  to  the  jail,  or  when  it  is  found  by  the  verdict  of 
another  jury  that  a  prisoner  whose  trial  or  sentence  was  suspended 
by  reason  of  his  being  found  to  be  insane,  has  been  restored,  if  already 
convicted,  he  shall  be  sentenced,  and,  if  not,  the  court  shall  proceed  to 
try  him  as  if  no  delay  had  occurred  on  account  of  his  insanity. 


WISCONSIN. 


The  management  of  the  insane  asylums  is  in  the  hands  of  the  State 
board  of  supervision  of  Wisconsin  charitable,  reformatory,  and  penal  in- 

1  Revised  Statutes  of  Wisconsin,  1878,  pp  60,  205-215,  462,  520,  661,  662,  973- 
975,  1042,  1098,  1099.  1139,  1140.  Laws  of  Wisconsin,  1880,  pp.  121,  122,  299-302, 
317;  1881,  pp.  245,  246,  274,  275,  283-287,  376,  378-388;  1882,  pp.  400,  914;  1883, 
Yol.  I.  pp.  24-28,  128.  129,  135-138. 


686  APPENDIX  —  WISCONSIN. 

stitutions,  which  acts  as  commissioners  of  lunacy,  with  power  to  investi- 
gate the  question  of  the  insanity  and  condition  of  any  person  committed 
or  confined  in  any  lunatic  hospital  or  asylum,  public  or  private,  or  re- 
strained of  his  liberty  by  reason  of  alleged  insanity.  The  board  shall 
take  the  proper  legal  steps  for  the  discharge  of  any  person  so  committed 
or  restrained,  if,  in  its  opinion,  such  person  is  not  insane,  or  can  be  cared 
for  after  such  discharge  without  danger  to  others  and  with  benefit  to 
himself  Any  letter,  communication  or  complaint,  addressed  to  such 
board,  or  to  any  member  thereof,  by  any  inmate  or  employe  in  any  of 
said  institutions,  shall  be  forwarded  as  addressed,  without  being  opened 
or  interfered  with. 

Patients  shall  be  admitted  to  the  hospitals  for  the  insane  from  the 
several  counties  in  the  ratio  of  their  population,  but  each  county  shall 
be  entitled  to  at  least  two  patients,  if  desired.  No  person  idiotic  from 
birth  shall  be  admitted ;  and  no  person  shall  be  retained  in  either  hospital 
after,  by  a  fair  trial,  it  shall  have  become  reasonably  certain  that  such 
person  is  incurably  insane,  if  the  room  is  wanted  for  cases  of  a  more 
hopeful  character.  But  no  person  in  the  hospitals  committed  as  an 
insane  criminal  shall  be  discharged  without  an  order  of  the  court  having 
jurisdiction  over  such  person. 

Whenever  any  resident  of  this  State,  or  any  person  found  therein 
whose  residence  cannot  be  ascertained,  shall  be,  or  be  supposed  to  be, 
insane,  application  may  be  made  in  his  behalf  by  any  respectable  citizen 
to  the  judge  of  the  county  court,  judge  of  the  circuit  court,  or  any  judge 
of  a  court  of  record  in  and  for  the  county  in  which  the  patient  resides, 
or,  in  case  his  residence  is  unknown,  the  county  in  which  he  is  found, 
for  a  judicial  inquiry  as  to  his  mental  condition,  and  for  an  order  of  com- 
mitment to  some  hospital  or  asylum  for  the  insane. 

The  application  shall  be  in  writing,  and  shall  specify  whether  or  not 
a  trial  by  jury  is  desired  by  the  applicant.  The  judge  applied  to  shall 
appoint  two  disinterested  physicians  of  good  repute  for  medical  skill  and 
moral  integrity  to  visit  and  examine  the  person  alleged  to  be  insane. 
Such  physicians  shall  forthwith,  by  personal  examination,  satisfy  them- 
selves as  to  the  patient's  condition  and  report  to  the  judge.  Such  report 
shall  cover  twenty-nine  prescribed  points  touching  the  history  and  con- 
dition of  the  patient.  Upon  the  receipt  of  the  physicians'  report  the 
judge  may,  if  no  demand  has  been  made  for  a  jury,  make  his  order  of 
commitment  to  the  hospital  or  asylum  of  the  district  to  which  the  county 
belongs,  or,  if  not  fully  satisfied,  may  make  further  investigation  of  the 
case.  At  any  stage  of  the  proceedings,  and  before  the  actual  confinement 
of  the  person,  he,  or  any  relative  or  friend  acting  in  his  behalf,  shall  have 
the  right  to  demand  that  the  question  of  sanity  be  tried  by  a  jury.  In 
case  a  trial  by  jury  is  demanded,  the  forms  of  procedure  shall  be  the 
same  as  in  trials  by  jury  in  justices'  courts,  and  the  trial  shall  be  in  the 
presence  of  the  person  supposed  to  be  insane,  and  his  counsel  and  imme- 
diate friends,  and  the  medical  witnesses.  All  other  persons  shall  be  ex- 
cluded. If  the  jury  find  the  person  sane,  he  shall  be  discharged.  If 
they  find  him  insane,  and  a  fit  person  to  be  sent  to  a  hospital  for  the 
insane,  they  shall  so  state. 

The  physician's  report  or  certificate  shall  be  sent  with  the  patient  to 


APPENDIX — WISCONSIN,  537 

the  hospital  or  asylum.  All  proceedings  relating  to  the  commitment  of 
insane  persons  shall  be  filed  Avith  the  county  judge  of  the  county  in  Avhich 
the  insane  person  resides,  who  is  required  to  keep  a  record-book,  in  which 
all  proceedings  shall  be  recorded,  and  be  open  to  inspection.  Whenever, 
in  the  opinion  of  the  judge  applied  to,  the  public  safety  requires  it,  he 
may  order  the  sheriff  forthwith  to  take  and  confine  the  supposed  insane 
person  in  some  place  specified,  until  the  further  proceedings  for  his  com- 
mitment can  be  had,  or  until  the  further  order  of  the  judge.  Or  if,  after 
the  receipt  by  the  judge  of  the  report  of  the  examining  physician,  he 
deems  it  proper,  he  may  order  the  sheriff  then  to  take  the  alleged  insane 
person  into  custody,  and  keep  him  in  some  place  specified  until  the 
further  order  of  the  judge. 

When  any  respectable  citizen  has  reason  to  question  the  propriety  or 
justice  of  the  confinement  of  any  patient  committed  to  any  hospital  or 
asylum,  he  may  apply  to  any  of  the  judges  above  mentioned  of  the  county 
in  which  such  person  resides,  asking  for  a  rehearing  and  a  further  judi- 
cial inquiry  as  to  the  mental  condition  of  such  person.  The  proceedings, 
upon  the  rehearing,  shall  be  substantially  the  same  as  upon  the  original 
commitment.  If,  upon  such  rehearing,  the  patient  is  found  to  be  sane, 
an  order  shall  be  made  that  he  be  set  at  liberty.  If  it  is  determined  that 
he  is  insane,  no  further  action  shall  be  taken  upon  the  application. 

No  person  not  deemed  dangerous  when  at  large  shall  be  committed  to 
any  hospital  or  asylum  for  the  insane  solely  on  account  of  physical  in- 
firmity or  mental  imbecility. 

If  any  relative  or  friend  of  a  patient  committed  to  any  hospital  desires 
to  perform  the  duty  of  taking  him  to  the  hospital,  and  is  competent  to  do 
so,  the  warrant  of  commitment  may  be  delivered  to  and  executed  by  him, 
instead  of  by  the  sheriff. 

Each  patient  sent  to  the  hospital  must  be  furnished  with  the  amount 
of  clothing  prescribed,  or  he  may  be  rejected  by  the  superintendent. 

When  a  patient  is  discharged  as  cured,  the  superintendent  shall  furnish 
him  with  suitable  clothing,  and  a  sum  of  money  not  exceeding  $20. 

If  the  relatives  or  friends  of  any  patient  shall  ask  the  discharge  of 
such  patient  before  he  has  recovered  from  his  insanity,  the  superintendent 
may,  in  his  discretion,  require  a  bond  to  be  executed,  conditioned  for  the 
safe  keeping  of  such  patient. 

Incurable  and  harmless  patients  shall  be  discharged  whenever  it  is 
necessary  to  make  room  for  recent  or  more  hopeful  cases,  except  in  case 
of  persons  under  the  charge  of,  or  conviction  of,  crime. 

When  an  order  is  made  for  the  removal  of  a  patient,  the  superinten- 
dent, except  when  friends  are  willing  to  receive  the  patient,  shall  notify 
the  county  judge  of  the  county  from  which  the  patient  was  sent,  and  he 
shall  issue  his  warrant,  directing  the  sheriff  to  remove  the  patient  to  the 
poor-house  or  jail  in  the  county  whence  he  was  taken.  Patients  in  either 
of  the  hospitals  found  to  be  non-residents  of  the  State  shall,  when  prac- 
ticable, be  transferred  to  the  proper  oflScers  of  their  own  State. 

The  several  courts  of  record  in  the  State  shall  be  authorized  to  commit, 
for  safe  keeping  and  treatment,  to  either  hospital  for  the  insane,  any 
person  who  shall  be  under  charge  of,  or  convicted  before  such  court  of, 
any  crime  punishable  by  imprisonment  in  the  State  Prison  and  awaiting 


538  APPENDIX  —  WISCONSIN. 

hearing,  trial,  conviction,  or  sentence,  on  account  of  alleged  insanity  at 
the  time  of  the  commission  of  such  crime,  or  at  any  time  afterwards  and 
prior  to  sentence.  Whenever  it  is  found  by  an  examination  duly  made 
that  such  a  patient  is  no  longer  insane,  the  judge  of  the  court  from  which 
such  person  was  sent,  and  the  district  attorney  of  the  proper  county, 
shall  be  notified,  and  it  shall  be  the  duty  of  such  judge  to  make  an  order 
for  the  removal  of  such  person  to  the  common  jail  of  the  county  from 
which  such  person  was  sent,  to  be  detained  in  such  jail  until  further  dealt 
with  according  to  law,  or  until  discharged  therefrom  in  pursuance  of  law. 

Whenever  any  person  tried  for  any  criminal  offence  is  acquitted  on  the 
ground  that  he  was  insane  at  the  time  of  the  alleged  offence,  if  he  has 
recovered  his  sanity  at  the  time  of  trial,  he  shall  be  discharged,  but,  if  he 
is  still  insane,  he  shall  be  confined  in  one  of  the  State  hospitals  for  the 
insane,  to  be  kept  as  other  patients  are  kept  and  treated  therein. 

When  any  person  is  indicted  or  informed  against  for  any  offence,  if 
there  is  a  probability  that  such  accused  person  is  at  the  time  of  trial  in- 
sane and  incapacitated  to  act  for  himself,  the  court  shall,  in  a  summary 
manner,  make  inquisition  by  a  jury  or  otherwise,  as  it  deems  most  proper. 
If  it  is  thus  found  that  such  accused  person  is  insane,  his  trial  shall  be 
postponed  indefinitely,  and  the  court  shall  thereupon  order  that  he  be 
confined  in  one  of  the  State  hospitals  for  the  insane.  Upon  the  recovery 
of  such  person,  he  shall  be  committed  to  the  county  jail  of  the  county 
where  the  indictment  or  information  is  pending,  or  held  to  bail  for  his 
appearance  at  the  next  succeeding  term  of  said  court  for  trial  of  such 
offence.  If  the  accused  is  found  to  be  incurably  insane,  he  shall  be  treated 
and  disposed  of  as  other  cases  of  incurable  insanity  according  to  law. 

Whenever  it  shall  appear  to  the  satisfaction  of  the  Governor  by  the 
representation  of  the  warden  and  directors  of  the  State  Prison,  and  by 
examination,  that  any  person  confined  therein  has  become  insane  during 
his  imprisonment,  and  is  still  insane,  he  may  make  an  order  that  such 
insane  person  be  confined  and  treated  in  one  of  the  State  hospitals  for 
the  insane,  and,  upon  his  recovery,  if  before  the  expiration  of  his  sentence, 
that  he  be  returned  to  the  State  Prison. 

Insane  criminals  and  persons  acquitted  of  crime  on  the  ground  of  in- 
sanity, may  be  transferred  to  the  Milwaukee  County  Asylum  for  the  In- 
sane as  well  as  to  the  State  asylums. 

Whenever  it  is  made  to  appear  to  a  county  judge,  by  a  petition  of  a 
majority  of  the  supervisors  of  any  town,  of  the  common  council  of  any 
city,  or  of  the  board  of  trustees  of  any  village,  that  the  public  safety  re- 
quires the  close  custody  of  any  poor  insane  person  of  such  town,  city,  or 
village,  the  judge  shall  direct  the  sheriff  forthwith  to  take  and  confine 
such  insane  person  in  some  proper  place  specified.  Such  insane  person, 
when  so  confined,  shall  be  subject  to  the  directions  of  the  said  judge,  and 
shall  receive  such  care,  attention,  and  treatment  as  such  judge  shall  deem 
proper  and  necessary. 

Whenever  there  is  not  room  in  the  State  asylums  for  the  insane  of  any 
county,  such  county  may  establish  a  county  insane  asylum.  Upon  the 
completion  of  such  asylum,  all  inmates  of  the  State  institutions  for  the 
insane  committed  from,  or  belonging  to,  such  county,  held  as  chronic  or 
incurable,  and  all  insane  inmates  of  the  poor-house  of  such  county,  and 


APPENDIX — WYOMING.  589 

all  other  persons  belonging  to  said  county  and  duly  adjudged  to  be  in- 
sane, may  be  transferred  to  said  county  asylum  :  provided,  however,  that 
when  any  patient  committed  to  the  county  asylum  is  found  to  belong  to 
the  class  defined  as  acute  insane,  and  to  require  permanent  and  special 
treatment  for  the  purpose  of  cure,  such  person  may  be  transferred  to  the 
State  hospitals  for  the  insane.  When  there  is  any  room  in  any  such 
county  insane  asylum  for  more  than  the  patients  of  the  county,  patients 
from  any  other  county  may  be  received  and  cared  for.  A  portion  of  the 
expense  of  erecting  such  county  insane  asylums,  and  of  keeping  patients 
therein,  is  paid  by  the  State  upon  certain  conditions  and  stipulations. 
Whenever  any  county  has  not  made  suitable  provisions  for  the  proper 
and  humane  care  of  its  chronic  or  its  acute  insane,  the  board  of  charities 
or  reform  may  direct  the  removal  of  either  class  of  said  insane  to  any 
county  asylum,  or  to  any  other  county  possessing  suitable  accommoda- 
tions therefor  for  care  or  medical  treatment,  as  the  circumstances  seem 
to  require. 

Corporations  may  be  formed  for  maintaining  private  insane  asylums 
for  the  care  and  treatment  of  insane  and  feeble-minded  persons.  Any 
insane  or  feeble-minded  person  may,  upon  the  written  request  of  the 
guardian,  or  any  friend  of  such  person,  be  committed  to  any  such  private 
hospital  or  asylum  in  the  same  manner  that  insane  persons  are  committed 
to  the  State  Hospital  for  the  Insane. 

Insane  or  feeble-minded  persons  may  voluntarily  place  themselves 
under  the  care  and  treatment  of  any  such  hospital,  asylum,  or  institution. 

All  such  private  asylums  are  subject  to  substantially  the  same  rules 
and  provisions  for  supervision  and  visitation  as  the  State  hospitals  for  the 
insane. 

Any  person  neglecting  or  abusing  an  inmate  of  an  asylum  for  the  in- 
sane shall  be  liable  to  a  fine  of  $200,  or  one  year's  imprisonment. 


WYOMING.^    (Tereitory.) 

There  is  no  insane  asylum  in  Wyoming.  Patients  are  sent  to  the 
Iowa  Hospital  for  the  Insane,  and  elsewhere.  Each  county  has  the 
responsibility  of  caring  for,  and  paying  the  expenses  of,  its  pauper 
insane. 

If  information  in  writing  be  given  to  the  probate  judge  that  any  per- 
son in  the  county  is  an  idiot,  lunatic,  or  person  of  unsound  mind,  and 
praying  that  an  inquiry  thereinto  be  had,  the  court,  if  satisfied  that  there 
is  good  cause  for  the  exercise  of  its  jurisdiction,  shall  cause  the  facts  to 
be  inquired  into  by  a  jury.     If  the  court  is  not  in  session,  a  special  term 

1  The  Compiled  Laws  of  Wyoming,  1876,  pp.  35,  161,  162,  248,  249,  280,  295,  472- 
476.     Session  Laws  of  Wyoming,  1882,  pp.  132,  133. 


540  APPENDIX WYOMING. 

may  be  called  for  the  purpose  of  holding  an  inquiry.  The  probate  court 
may  cause  the  person  alleged  to  be  of  unsound  mind  to  be  brought  before 
it,  in  its  discretion,  in  the  course  of  the  proceedings.  Whenever  any 
judge  of  the  probate  court,  justice  of  the  peace,  sheriff,  coroner,  or  con- 
stable shall  discover  any  person,  resident  of  his  county,  to  be  of  unsound 
mind,  it  shall  be  his  duty  to  make  application  to  the  probate  court,  and 
thereupon  like  proceedings  shall  be  had  as  in  the  case  of  information  by 
unofficial  persons.  If  it  be  found  by  the  jury  that  the  person  inquired 
about  is  of  unsound  mind,  and  incapable  of  managing  his  affairs,  the  court 
shall  appoint  a  guardian  of  the  person  and  estate  of  such  person. 

The  court  may,  if  just  cause  appears,  at  any  time  during  the  term  at 
which  an  inquisition  is  had,  set  the  same  aside,  and  cause  a  new  jury  to 
be  impanelled  to  inquire  into  the  facts ;  but  when  two  juries  concur  in 
any  case,  the  verdict  shall  not  be  set  aside. 

Every  guardian  of  a  person  of  unsound  mind  shall  give  a  bond  condi- 
tioned that  he  will  take  due  and  proper  care  of  such  insane  person  and 
of  his  property,  and  will  faithfully  do  and  perform  all  things  enjoined 
upon  him  by  the  order  of  the  court.  Every  such  guardian  shall  take 
charge  of  the  person  committed  to  his  charge,  and  provide  for  his  support 
and  maintenance. 

If  any  person  by  lunacy  or  otherwise  shall  be  ftiriously  mad,  or  so  far 
disordered  in  his  mind  as  to  endanger  his  own  person,  or  the  person  or 
property  of  others,  it  shall  be  the  duty  of  his  guardian,  or  other  person 
under  whose  care  he  may  be,  to  confine  him  in  some  suitable  place  until 
the  next  sitting  of  the  probate  court  of  the  county,  which  shall  make  such 
order  for  the  restraint,  support,  and  safe  keeping  of  such  person  as  the 
circumstances  may  require. 

If  any  such  person  furiously  mad  shall  not  be  confined  by  the  person 
having  charge  of  him,  or  there  be  no  person  having  such  charge,  any 
judge  of  a  court  of  record,  or  any  two  justices  of  the  peace,  may  cause 
such  insane  person  to  be  apprehended,  and  may  employ  any  person  to 
confine  him  in  some  suitable  place  until  the  probate  court  shall  make 
further  order  therein. 

If  any  person  shall  allege  in  writing,  verified  by  oath,  that  any  person 
declared  to  be  of  unsound  mind  has  been  restored  to  his  right  mind,  the 
court  by  which  the  proceedings  were  had  shall  cause  the  facts  to  be  in- 
quired of  by  a  jury.  If  it  shall  be  found  that  such  person  has  been 
restored  to  his  right  mind,  he  shall  be  discharged  from  care  and  custody. 

Any  person  that  becomes  lunatic  or  insane  after  the  commission  of  a 
crime  or  misdemeanor  ought  not  to  be  tried  for  the  offence  during  the 
continuance  of  the  lunacy  or  insanity.  If,  after  verdict  of  guilty,  and 
before  judgment  pronounced,  such  person  becomes  lunatic  or  insane,  no 
judgment  shall  be  given  while  such  lunacy  or  insanity  continues.  If, 
after  judgment  and  before  execution,  such  person  becomes  insane,  then, 
in  case  the  punishment  be  capital,  the  execution  thereof  shall  be  stayed 
until  the  recovery  of  such  person  from  the  insanity.  In  all  these  cases, 
it  shall  be  the  duty  of  the  court  to  impanel  a  jury  to  try  the  question 
whether  the  accused  be  at  the  time  of  impanelling  insane  or  not. 

If  any  convict  sentenced  to  the  punishment  of  death  shall  appear  to 
be  insane,  the  sherifi"  shall  give  notice  to  a  judge  of  the  district  court  of 


APPENDIX — UNITED    STATES.  541 

the  judicial  district,  and  shall  summon  a  jury  of  twelve  men  to  inquire 
into  such  insanity,  at  a  time  and  place  fixed  by  the  judge,  and  shall  give 
notice  to  the  prosecuting  attorney.  If  it  be  found  that  the  convict  is 
insane,  the  judge  shall  suspend  the  execution  of  the  convict  until  such 
time  a§  the  Governor  shall  direct  his  execution.  The  Governor  shall  be 
notified  of  the  proceedings  and  the  finding,  and,  as  soon  as  he  is  con- 
vinced that  the  convict  has  become  of  sound  mind,  he  may  issue  a  warrant 
appointing  a  time  for  his  execution. 


UNITED  STATES.^    (District  of  Columbia.) 

The  chief  executive  ofiicer  of  the  Government  Hospital  for  the  Insane 
of  the  Army  and  Navy  of  the  United  States  and  of  the  District  of 
Columbia  is  the  superintendent,  appointed  by  the  Secretary  of  the 
Interior. 

He  shall,  upon  the  order  of  the  Secretary  of  War,  the  Secretary  of 
the  Navy,  and  the  Secretary  of  the  Treasury  respectively,  receive  and  keep 
in  custody,  until  they  are  cured  or  removed  by  the  same  authority  which 
ordered  their  reception :  (1)  Insane  persons  belonging  to  the  army, 
navy,  marine  corps,  and  revenue  cutter  service.  (2)  Civilians  employed 
in  the  quartermaster's  and  subsistence  departments  of  the  army,  who 
may  be,  or  may  become,  insane  while  in  such  employment.  (3)  Men 
who  while  in  the  service  of  the  United  States,  in  the  army,  navy,  or 
marine  corps,  have  been  admitted  to  the  hospital  and  have  been  dis- 
charged on  the  supposition  that  they  were  cured,  and  who  have  within 
three  years  after  such  discharge  become  again  insane  from  causes  exist- 
ing at  the  time  of  such  discharge,  and  have  no  adequate  means  of  support. 
(4)  Indigent  insane  persons  who  have  been  in  either  of  the  said  services 
and  have  been  discharged  therefrom  on  account  of  disability  arising  from 
such  insanity.  (5)  Indigent  insane  persons  who  have  become  insane 
within  three  years  after  their  discharge  from  such  service  from  causes 
which  arose  during  and  were  produced  by  such  service. 

Also  persons  in  the  marine-hospital  service  becoming  insane  may  be 
admitted  to  the  Government  Hospital  for  the  Insane  upon  the  order 
of  the  Secretary  of  the  Treasury.  Any  inmate  of  the  National  Home 
for  Disabled  Volunteer  Soldiers  who  is  or  may  become  insane,  shall  upon 
an  order  of  the  President  of  the  Board  of  Managers  of  the  National 
Home  be  admitted  to  said  insane  hospital  and  treated  therein.  The 
Secretary  of  the  Navy  may  cause  persons  in  the  naval  service,  or  marine 
corps,  who  become  insane  while  in  the  service,  to  be  placed  in  such  hos- 
pital for  the  insane  as  in  his  opinion  will  be   most  convenient   and 

1  Eevised  Statutes  of  the  United  States,  1873-1874,  pp.  263, 945-948.  Supplement  to 
the  Kevised  Statutes  of  the  United  States,  Vol.  I.,  1874-1881,  pp.  104,  191,  289,  461, 
559.     United  States  Statutes,  1881-1882,  pp.  329,  330. 


542  APPENDIX  —  UNITED    STATES. 

best  calculated  to  effect  a  cure ;  and  he  is  not  restricted  to  the  Govern- 
ment Hospital  for  the  Insane. 

All  indigent  insane  persons,  residents  in  the  District  of  Columbia  at 
the  time  they  became  insane,  shall  be  entitled  to  the  benefits  of  the  hos- 
pital for  the  insane,  and  shall  be  admitted  on  the  order  of  the  executive 
authority  of  the  District.  The  Secretary  of  the  Interior  may  grant  an 
order  for  admission  into  the  hospital,  when  application  is  made  in  writing 
by  a  member  of  the  board  of  visitors,  accompanied  by  the  certificate  of  a 
judge  of  the  supreme  court  for  the  District  of  Columbia,  or  of  any  justice 
of  the  peace  of  the  District.  It  must  appear  by  this  certificate  that  two 
respectable  physicians,  residents  of  the  District,  appeared  before  said 
judge  or  justice  and  deposed  in  writing  that  they  knew  the  person  alleged 
to  be  insane;  that,  from  personal  examination,  they  believed  Kim  to  be 
insane  and  a  fit  subject  for  treatment  in  the  hospital:  and  that  he  was  a 
resident  of  the  District  when  seized  with  the  mental  disorder  then  afflict- 
ing him.  It  must  further  appear  by  said  certificate  that  two  respectable 
householders,  residents  of  the  District,  appeared  before  said  judge  or 
justice  and  deposed  in  writing  that  they  knew  the  person  alleged  to  be 
insane,  and  from  personal  examination  believed  such  insane  person 
unable  to  support  himself  or  himself  and  family,  if  he  have  one,  and 
unable  to  pay  his  board  in  the  hospital.  The  affidavits  of  said  physicians 
and  householders  shall  accompany  the  certificate  of  the  judge  or  justice. 

The  application  must  be  made  within  five  days  after  the  date  of  the 
affidavits,  and  it  must  appear  that  the  visitor  applying  has  examined  the 
affidavits  and  certificate.  It  shall  be  the  duty  of  such  visitor  to  withhold 
his  application  if  he  has  reason  to  doubt  the  indigence  of  the  insane 
person. 

The  order  of  the  Secretary  of  the  Interior  being  granted,  any  police 
officer  or  constable  may  assist  in  carrying  such  insane  person  to  the 
hospital. 

If  the  patient  is  found  to  have  some  property,  he  may  be  required  to 
pay  such  part  of  his  expenses  in  the  hospital  as  may  be  just  and  reason- 
able. 

Any  indigent  insane  person  who  did  not  reside  in  the  District  at  the 
time  he  became  insane,  may  be  received  into  the  hospital  in  like  manner, 
to  stay  temporarily,  until  it  can  be  ascertained  who  his  friends  are,  or 
whence  he  came. 

Whenever  there  are  vacancies,  private  patients  from  the  District  may 
be  received,  the  rate  of  board  to  be  determined  by  the  visitors.  The  pay 
patients  may  be  received  on  the  certificate  of  two  respectable  physicians 
of  the  District,  stating  that  they  have  personally  examined  the  patient, 
and  believe  him  to  be  insane,  and  a  fit  subject  for  treatment  in  the  hos- 
pital. There  must  be  also  a  written  request  for  the  admission  from  the 
nearest  relatives,  legal  guardian,  or  friend  of  the  patient.  The  request 
must  be  made  within  five  days  of  the  date  of  the  certificate  of  insanity. 

If  any  person  will  give  bond,  with  sufficient  security,  to  restrain  and 
take  care  of  any  pay,  or  any  indigent,  insane  person,  not  charged  with  a 
breach  of  the  peace,  whether  in  the  hospital  or  not,  the  supreme  court  of 
the  District,  or  any  judge  thereof,  in  vacation,  may  deliver  the  patient  to 
him,  to  be  kept  until  restored  to  sanity. 


APPENDIX  —  UNITED    STATES.  643 

If  any  person  charged  with  crime  be  found  in  the  court  before  which 
he  is  so  charged  to  be  an  insane  person,  such  court  shall  certify  the  same 
to  the  Secretary  of  the  Interior,  who  may  order  such  person  to  be  con- 
fined in  the  Hospital  for  the  Insane. 

Any  person  becoming  insane  during  the  continuance  of  his  sentence 
in  the  United  States  Penitentiary  shall  have  the  same  privilege  of  treat- 
ment in  the  hospital  during  the  continuance  of  his  mental  disorder  as  is 
granted  above  to  persons  who  escape  the  consequences  of  criminal  acts 
by  reason  of  insanity.  If  it  be  the  opinion  both  of  the  physician  to  the 
penitentiary  and  the  superintendent  of  the  hospital  that  such  insane  con- 
vict is  so  depraved  and  furious  in  his  character  as  to  render  his  custody 
in  the  hospital  insecure,  and  his  example  pernicious,  he  shall  not  be 
received. 

When  any  person,  confined  in  the  Hospital  for  the  Insane,  charged 
with  crime,  and  subject  to  be  tried  therefor,  or  convicted  of  crime,  and 
undergoing  sentence  therefor,  shall  be  restored  to  sanity,  the  superinten- 
dent of  the  hospital  shall  give  notice  to  the  judge  of  the  criminal  court, 
and  deliver  him  to  the  court,  in  obedience  to  the  proper  precept. 

No  insane  person,  not  charged  with  any  breach  of  the  peace,  shall  be 
confined  in  the  United  States  Jail,  in  the  District  of  Columbia. 

Upon  the  application  of  the  Attorney-General,  the  Secretary  of  the 
Interior  shall  transfer  to  the  Government  Hospital  for  the  Insane,  in  the 
District  of  Columbia,  all  persons  who,  having  been  charged  with  offences 
against  the  United  States,  are  in  the  actual  custody  of  its  officers,  and 
all  persons  who  have  been  or  shall  be  convicted  of  any  offence  in  a  court 
of  the  United  States,  and  are  imprisoned  in  any  State  prison  or  peniten- 
tiary of  any  State  or  Territory,  and  who,  during  their  term  of  imprison- 
ment, have  or  shall  become  insane.  In  all  cases  where  there  shall  not  be 
accommodation  for  such  insane  convicts  in  the  Insane  Asylum  of  the 
District  of  Columbia,  or  if,  for  other  reasons,  the  Attorney- General  is  of 
opinion  that  such  insane  person  should  be  placed  at  a  State  insane  asylum, 
rather  than  at  said  District  Asylum,  then  the  Attorney-General  shall 
have  power,  in  his  discretion,  to  contract  with  any  State  insane  or  lunatic 
asylum  within  the  State  in  which  such  convict  is  imprisoned  for  his  care 
and  custody  while  he  remains  insane.  Whenever  such  insane  convict 
shall  be  restored  to  sanity,  he  shall  be  returned  to  the  prison  or  peniten- 
tiary from  which  the  transfer  was  made,  provided  the  term  of  imprison- 
ment shall  not  have  expired. 

The  questions  of  sanity  in  all  such  cases  shall  be  determined  in  accord- 
ance with  the  rules  and  regulations  of  existing  laws.  State  or  national, 
on  the  subject,  applicable  to  the  prison,  penitentiary,  or  asylum  where 
such  convict  shall  be  confined. 


INDEX. 


ACUTE  mania,  136 
Adolescence,  insanity  of,  379 
mortality  in,  387 
progress  in,  386 
recovery  in,  signs  of,  in,  382 
symptoms  of,  379 
treatment  of,  383 
psychology  of,  375 
Affections  cooled  by  insanity,  140 
Aftective  insanity,  231 
Ague,  insanity  from,  417 
Alabama,  laws  respecting  insane,  439 
Alcohol  a  cause  of  insanity,  312 
Alcoholic  degeneration,  317 

insanity,  312 
Alcoholism,  acute,  313 

chronic,  315 
Alimentation  psychologically  considered, 

39 
Alternating  insanity,  170 
Alternation  in  insanity,  170 
Amenorrhtt'al  insanity,  336 
Amentia,  43,  204 

Ana?mia  in  insanity  of  lactation,  360 
Ana?mic  brain,  326,  360 

insanity,  411 
Animal  food,  its  effects  on  neurotic  chil- 
dren, 167,  384 
impulse,  244 
Aphasia,  case  of,  278 
Appointments  in  lunacy,  36 
Arizona,  laws  respecting  insane,  440 
Arkansas,  laws  respecting  insane,  441 
Arteries,  lesions  of,  in  brain  syphilis  (Plate 

VIII.  Fig.  1),  305 
Arteritis,  syphilitic,  302,  305,  306 
Asthma,  insanity  of,  416 


BAILLAKGEK  first  described  circular 
insanity,  171 

Baths,  hot,  in  mania,  145,  155 
in  melancholia,  120,  211 
Turkish,  in  melancholia,  120,  211 

Belladonna  as  a  sleep  producer,  169 

Benedick  on  the  brains  of  criminals,  232 

Bird,  G.,  on  oxaluria,  415 

Blistering  in  mania,  154 

Boils  in  mania,  154 

Brain,  anajmic,  326 


Brain,  functions  of,  as  related  to  mental 
diseases,  46-49 
pathological  disorders  of,  45 
Bright's  disease,  insanity  in,  414 
Bromides  as  hypnotics,  168 
in  circular  insanity,  187 
in  epilepsy,  295,  297 
in  mania,  146 
Brown,  J.  J.,  on  a  new  lesion  in  acute 
mania  (Plate  YII.  Fig.  2;    Plate 
VIII.  Figs.  1,  2,  5),  92 
on  lesions  in  senile  dementia,  408 
on  syphilitic  arteritis,  305 
Bucknill   and   Tuke    on    post-febrile   in- 
sanity, 417 


CADELL,  Dr.,  his  case  of  syphilitic  in- 
sanity, 302 
California,  laws  respecting  insane,  442 
Campbell,  J.  A  ,  cases  of  melancholia,  74 

413 
Camphor  as  a  sleep  producer,  147,  169 
Cannabis  Indica  in  alternating  insanity 
187 
in  mania,  146 
in  melancholia,  94 
Cat,  maternal  instinct  in,  235 
Certificates  for  Curator  Bonis,  427 

for  treatment  in  private  houses,  424 
of  lunacy,  35,  424 
of  sanity,  427 
Chancery,  afiidavits  for,  427 
Children,  insanity  in  sensitive,  55,  121 
Chloral  as  a  sleep  producer,  168 
insanity  from  use  of,  318 
use  and  dangers  of,  in  mania,  146 
Choroii,  delirium  of,  324 

its  connection  with  rheumatism,  319 
Choreic  insanity  in  early  youth,  324 
its  epidemic  forms,  325 
prognosis  in,  324 
treatment  of,  325 
Circular  insanity,  170 
causes  of,  184 
duration  of,  174-177 
frequency  of,  183 
its  nature,  171 
pathology  of,  187 
symptoms  of,  180 


35 


546 


INDEX. 


Circular  insanity,  termination  of,  184 

treatment  of,  185 
Clark,  Campbell,  his  case  of  hydrocephalic 

idiocy,  215 
Classification  of  insanity,  44,  45 
Climacteric  insanity,  388 

pathological  appearances  in,  398 
prognosis  in,  393 
statistics  of,  393 
suicidal  longings  in,  389 
symptoms  of,  389 
Climacteric  in  man,  391 
in  woman,  389 
psychology  of,  388 
Colorado,  laws  respecting  insane,  444 
Competitive  examinations,  mischief  from, 

121 
Congestion  of  brain  in  acute  mania  (Plate 

III.),  156 
Conium  in  acute  mania,  147 
Connecticut,  laws  respecting  insane,  445 
Connubial  affection  altered  in  climacteric 

insanity,  388 
Conscience  a  brain  quality,  256 
Consciousness  lost  in  epilepsy,  295 
in  mania,  138 
in  stupor,  219 
Convolutions,  supply  of  blood  to  (Plate 
VII.  Fig.  5), '48 
their  structure  and  function,  46 
Convulsive  melancholia,  98 
Cretinism,  216 
Croom,   Dr.   Halliday,  on  perversions  of 

appetites,  during  menstruation,  336 
Oiirator  Bonis,  appointment  of,  427 
Cyanosis,  insanity  of,  416 


DAKOTA,  laws  respecting  insane,  448 
Deaf-mutism,  an  hereditary  neurosis, 
216 
Decoration,  insane,  190 
Delaware,  laws  respecting  insane,  450 
Delirium  in  young  children,  421 
Delirium  tremens,  50,  313 
De  lunatico  inquirendo,  427 
Delusions,  insane,  defined,  189 
should  be  tested,  50 
their  legal  importance,  201 
of  melancholia,  in  idiots,  188 

list  of,  88 
sane  and  insane,  88 
Delusional  mania,  157 

melancholia,  72 
Dementia,  alcoholic,  316 
its  varieties,  206 
organic,  206,  276 
primary,  212 
prognosis  in,  209 
secondary,  206 
senile,  395 
Demonomania,  84 
Deprivation,  idiocy  by,  216 

insanity  by,  418 
Destructive  impulse,  248 
Diabetic  insanity,  411 


Diabolic  possession,  superstition  of,  84 

Diathesis,  the  insane,  257 
doctrines  of,  39 

Diet  {see  Animal  Food)   in  circular  in- 
sanity, 185 
in  melancholia,  117 

Dietetic  management  of  the  nisus  genera- 
tivus,  346 

Dipsomania,  250 

Dipsomaniacs,  laws  respecting,  447 

District  of  Columbia,  laws  respecting  in- 
sane, 541 

Douse  on  prevalence  of  syphilis,  301 

Drunkards,  laws  respecting,  447,  462 

Duncan,  Dr.  Mathews,  on  fecundity,  375 


EDUCATION  of  girls,  369 
of  neurotic  children,  483 
Eggs  in  the  treatment  of  acute  mania,  148 
Electricity,   delusions  of   being   tortured 
by,  83 
in  detecting  feigned  insanity,  431 
in  stupor,  211,  224 
Enfeeblement,  morbid,  204 
Epileptic  insanity,  286 

counter-ijTitations  in,  296 
hallucinations  in,  293 
pathology  of,  292,  295 
prevalence  of,  297 
religious   emotionalism   in,   288. 

289 
suicidal  impulses  in,  293 
treatment  of,  295 
suicide  of  an,  294 
Epileptics,  criminal,  288 
Epileptiform  convulsions  in  general  paral- 
ysis, 268 
impulse,  243 
melancholia,  92 
Epilepsy  compatible  with  sanity,  286 

masked,  287 
Epithelial  granulations  in  ventricles  (Plate 

VII.  Fig.  3j,  274 
Ergot  in  melancholic  stupor,  224 
Erotomania,  286 
Esquirol's  classification,  42 
Exaltation,  physiological,  123 
Examining  patients,  rules  for,  49 
Excited  melancholia,  90 


FALKET  on  circular  insanity,  171 
Fattening  in  insanity  of  adolescence, 
888 
Fears,  morbid,  64,  199 
Feeding,  forcible,  107 
Ferrier  on  brain  localization,  82 
Flesh  meat.     See  Animal  Food. 
Florida,  laws  respecting  insane,  451 
Folie  a  double  forme,  170 
circulaire,  170 

commencement  of,  184 
pathology  of,  187 
termination  of,  184 
treatment  of,  185 


INDEX. 


547 


Folie  raisonnante,  135,  171 
Friends,  Society  of,  insanity  in,  381 


GENERAL  paralysis,  definition  of,  260 
etiology  and  distribution,  269, 276 
its  nature,  275 
pathology  of,  272 
prevalence  and  ages  (Plate  VI.), 

276 
stages  of,  260 

varieties,  pathological,  265 
symptomatological,  267 
Georgia,  laws  respecting  insane,  452 
Gouty  insanity,  prognosis  of,  325 
termination  in,  326 


H.^MATOMA  auris,  97,  265,  379 
Hallucination,  a,  defined,  139 
Hemiplegia,  277 

alternating,  92 
Hereditary  tendency,  39 

of  melancholic  diathesis,  115 
Home  treatment  expensive,  51 

its  advantages,  52 
Homicidal  impulse,  244 
mania,  162 
melancholia,  104 
Hygiene  in  neurotic  children,  432 
Hyoscyamine  in  mania,  146 
Hyoscyamus  as  a  hypnotic,  169 
Hyperkinesia,  231 
Hypnotics  in  insanity,  145 
Hypochondria,  55 
Hypochondriacal  melancholia,  67 
Hysterical  insanity,  840 
statistics  of,  341 
Hystero-epilepsy,  340 


IDAHO,  laws  respecting  insane,  454 
Idiocy,  by  deprivation,  217 
definition  of,  212 
eclampsic,  214 
epileptic,  214 
genetous,  213 
hydrocephalic,  215 
inflammatory,  215 
microcephalic,  215 
paralytic,  214 
traumatic,  215,  300 
Illegitimacy  a  cause  of  puerperal  insanity, 

356 
Illinois,  laws  respecting  insane,  455 
Illusion,  an,  defined,  139 
Imbecility,  212 

congenital,  212 
Impulse,  animal,  231 
destructive,  249 
homicidal,  231 
insane,  231 
suicidal,  231 
uncontrollable,  231 
Impulses,  morbid,  237 
Impulsive  insanity,  231 


Impulsive  insanity,  a  remarkable  case  of, 

238 
Incoherence   in  mania  (Plate   II.),   138, 

139 
Indecision,  morbid,  60 
Indiana,  laws  respecting  insane,  457 
Inebriate  apylums,  447 
Inhibitory  insanity,  231 

power,  defective,  231 
Inglis,  T.,  on  hystero-epilepsy   with    in- 
sanity, 340 
Insane  impulse,  231 
Insanity,  alcoholic,  312 

amenorrhceal,  336 

anaemic,  411 

by  deprivation,  418 

choreic,  319 

circular,  170 

climacteric,  388 

diabetic,  411 

epileptic,  286 

feigned,  431 

goutj%  325 

hysterical.  340 

inhibitory,  285 

metastatic,  416 

moral,  255 

of  adolescence,  397 

of  asthma,  416 

of  Bright's  disease,  414 

of  cardiac  disease,  416 

of  cyanosis,  416 

of  exophthalmic  goitre,  419 

of  lactation,  359 

of  lead-poisoning,  421 

of  masturbation,  342 

of  myxcederaa,  419 

of  oxaliiria,  415 

of  phosphaturia,  415 

of  pregnancy,  363 

of  puberty,  368 

ovarian,  336 

paralytic,  276 

phthi.sical,  326 

post-connubial,  421 

post-febrile,  416 

puerperal,  349 

rheumatic,  319 

senile,  395 

syphilitic,  301 

traumatic,  298 
Iowa,  laws  respecting  insane,  459 
Ireland,  W.  W..,  on  idiocy,  212 
Irritability  defined,  234 


JACKSON,  J.  HUGHLINGS,  on  epi- 
t)  leptic  insanity,  287 

on  syphilitic  insanity,  301 


KANSAS,  laws  respecting  insane,  462 
Katatonia,  182 
Kentucky,  laws  respecting  insane,  464 
Kleptomania,  45,  236,  254 


548 


INDEX. 


LACTATION,  insanity  of,  359 
prognosis  in,  363 
statistics  of,  363 
symptoms  of,  360 
treatment  of,  361 
Lawlessness,  organic,  232 
Laycock,  T.,  on  general  paralysis,  267 

on  organic  memory,  138 
Laziness  often  a  disease,  64 
Lead-poisoning,  insanity  of,  421 
Legal  views  about  insanity,  428 
Louisiana,  laws  respecting  insane,  466 
Lunatics,  their  number,  35 
Lycanthropia,  236 


MACLAEEN,  J.,  his  case  of  impulsive 
insanity,  238 
Maine,  laws  respecting  insane,  467 
Major  H.,  on  senile  brains  (Plate  VIII. 

Fig  4),  408 
Mania  a  potu,  317 
Mania,  43,  123 

acute,  136 

caused  by  a  new  lesion  (Plate  VIII. 
Fig.  5),  156 

chronic,  157 

definition  of,  124 

delusional,  157 

delusions  in,  165 

diet  in,  144 

ephemeral  (transitoria),  161 

first  stage  of,  137 

homicidal,  162 

in  children,  123 

periodic,  170 

prevalence  of  (Plate  VI.),  167 

prognosis  of,  165 

prophylaxis  in,  167 

recurrent,  170 

second  stage  of,  137 

simple,  125 

termination  of,  166 

treatment  of  acute,  144,  211 
Marriage  in  circular  insanity,  185 

in  masturbational  insanity,  347 

with  neurotic  persons,  431 
Maryland,  laws  respecting  insane,  470 
Massachusetts,  laws  respecting  insane,  471 
Massage,  63 

Masturbation,  insanity  of,  342 
bodily  signs  in,  343 
bromides  in,  347 
statistics  of,  347 
treatment  of,  346 

self-learned,  345 
Maudsley,  H.,  34 

on  phthisical  insanity,  328 

on  the  insane  diathesis,  257 
Mechanical  restraint  in  mania,  142 
Medical  psychology  defined,  34 
Medico-legal  duties  of  medical   men   in 

mental  diseases,  424 
Megalomania,  113,  190 
Melancholia,  bodily  symptoms  of,  114 


Melancholia,  causation  of,  115 

convulsive,  98 

definition  and  nature,  56 

delusional,  72 

delusions  in,  88 

epileptiform,  92 

excited,  90 

hereditary  predisposition  in,  115 

homicidal,  104 

hypochondriacal,  67 

inception  of,  113 

in  children,  421 

lesions  in  brain  in  (Plate  VII.  Fig. 
1),  76,  81,  82,  102 

organic,  100 

prevalence    and    ages    (Plate    VI.), 
114 

prognosis  of,  67,  115 

prophylaxis  of,  121 

religious,  84 

resistive,  94 

simple,  57 

suicidal,  104 

termination  of,  116 

treatment  of,  117,  211 
Melancholic  diathesis,  55 

persons,  54 
Melancholy  v.  malancholia,  56 
Melancholy,  hereditary,  55 
Memorv  in  acute  mania,  138 

morbid,  138 
Menstruation  in  acute  mania,  153 

insanity  from  suspended,  338 

psychology  of,  336 
Mental  conditions  liable  to  be  mistaken 

for  insanity,  50 
Metastatic  insanity,  416 
Michigan,  laws  respecting  insane,  475 
Mickle  on  the  use  of  opium,  120 
Milk  in  acute  mania,  144 

in  adolescent  insanity,  383 

in  melancholia,  117 
Minnesota,  laws  respecting  insane,  477 
Mississippi,  laws  respecting  insane,  479 
Missouri,  laws  respecting  insane,  480 
Monomania    (mono-psychosis),     43,    44, 
188 

diagnosis  of,  200 

of  grandeur,  190 

of  suspicion,  196 

of  unseen  agency,  193 

origin  of,  201 

prognosis  of,  202 

prophylaxis  of,  202 

treatment  of,  202 
Montana,  laws  respecting  insane,  483 
Moral  insanity,  255 

Pritchard's,  171 
Moreau  de  Tours  on  human  degeneration, 

312 
Morel  on  delirium  in  phthisis,  327 

on  human  degeneration,  312 
Morselli  on  suicide,  106 
Mouth-openers,  107 
Myxoedema,  419 


INDEX. 


549 


VTARCOTICS  in  mania,  146 

ll         in  melancholia,  120 

Nebraska,  laws  respecting  insane,  485 

Necrophilism,  236 

Neuralgia  analogous  to  melancholia,  42 

Neurasthenia,  63 

Neurosis,  insane,  45 

spasmodic,  45 
Nevada,  lav/s  respecting  insane,  488 
New  Hampshire,  laws  respecting  insane, 

489 
Newington,  Hayes,  on  alternating  hemi- 
*  plegia,  92 

on  anergic  stupor,  219 

on  mania  a  potu,  317 

on  syphilis  as  a  cause  of  insanity,  310 

on  syphilomatous  insanity,  304 
New  Jersey,  laws  respecting  insane,  491 
New  Mexico,  laws  respecting  insane,  494 
New  York,  laws  respecting  insane,  495 
Nitrite  of  amyl  in  mania,  146 
North   Carolina,  laws  respecting  insane, 
502 


OBSTINACY,  morbid,  in  melancholia, 
94 
Ohio,  laws  respecting  insane,  503 
Old  maid's  insanity,  339 
Opium  useful  against  sleeplessness,  169 

useless  in  mania,  146 

useless  in  melancholia,  120 
Oregon,  laws  respecting  insane,  507 
Organic  dementia,  276 

insanity,  275 

melancholia,  100 
Oxaluria,  insanity  of,  415 

period  of,  415 


PARALYSIS.     See  General  Paralysis. 
Paralysis  of  energy,  63 

of  feeling,  63 
Paralytic  insanity,  276 

analogies,  278 

causes,  277 

congestive  and   epileptiform  at- 
tacks in,  282 

pathology  of,  285 

recovery  in,  281 

statistics  of,  285 

symptoms  of,  278 
Pennsylvania,    laws    respecting    Insane, 

508 
Periodicity  in  mental  diseases,  170 
Phosphates  in  melancholia,  117 
Phosphaturia,  insanity  of,  415 
Phosphorus  in  mental  depression,  117 
Phthisica  spes,  334 
Phthisical  insanity,  326 

pathology  of,  331,  332 

prognosis  in,  334 

statistics  of,  327 

symptom's  of,  328 
Phthisis  common  among  the  insane,  327 
mental  condition  in,  329 


Pia  mater  adherent  in  general  paralvsis 

(Plate  I.),  273 
Planomania,  236 

Podagrous  insanity.    See  Gouty  Insanity. 
Post-connubial  insanity,  421 
Post-febrile  insanity,  416 
Pregnancy,  insanity  of,  363 

character  of,  364 

prognosis  in,  366 

statistics  of,  367 

suicidal  tendency  in,  366,  367 
psychology  of,  363 
Pritchard's  moral  insanity,  126 
Prout  on  oxaluria,  415 
Psychalgia,  43 
Psychlampsia,  43,  128 
Psychocoma,  44,  217 
Psychokinesia,  44,  231 

general,  238 
Psj-chology,  medical,  34 
Psychoneurosis,  44 
Psychoparesis,  43,  204 
Psychorhythm,  44,  170 
Puberty,  insanity  of,  368,  373 

period  of,  368 
Puerperal  insanity,  definition  of,  349 

frequency  of,  355 

heredity  in,  356 

pathology  of,  355 

prognosis  in,  358 

statistics  of,  355 

symptoms  of,  350 
Pyromania,  236 


QUININE    in    melancholia,    117,   211, 
354 


RAYNER  on  the  insanity  of  lead-poison- 
ing, 421 

Reasoning  insanity,  171 

Relapses  in  insanity,  170 

Religious  melancholia,  84 

Reproduction  psychologically  considered, 
40,  371 

Resistive  melancholia,  94 

Responsibility,  legal,  233 

Restraint  in  mania,  142 

Rheumatic  insanity,  319 

Rhode  Island,  laws  respecting  insane,  515 

Robertson,  A.,  on  the  insanity  of  lead- 
poisoning,  421 


O ATYRIASIS,  236 
kj     Savage  on  the  insanity  of  lead-poison- 
ing, 421 
Self-control,  sane  lack  of,  231 
Senile  insanity.  395 

hallucinations  of  hearing  in,  404 

management  of,  409 

motor  restlessness  in,  397 

pathology  of,  406 

prognosis  in,  405 

statistics  of,  396 


550 


INDEX. 


Senile  insanity,  treatment  of,  409 

Senility,  psychology  of,  395 

Sensibility  diminished  in  mania,  142 

Septic  inflammations  in  mania,  154 

Septicaemia  and  puerperal  insanity,  355 

Shower-baths,  211 

Skae,  C.  H.,  cases  of  trephining,  299 

Skae,  D.,  his  classification,  45 

Smith,  Willie,  the  homicide,  163 

Somnambulism,  421 

South  Carolina,  laws   respecting   insane, 

518 
Stewart,  H.  G.,  on  delusional  syphilitic 
insanity,  303 
on  monomania  of  unseen  agency,  194 
Stewart,  T.  G.,  on  insanity  from  Bright's 

disease,  414 
Stimulants  in  melancholia,  118 
Strychnine  in  mania,  147 
in  melancholia,  117 
in  threatened  dementia,  211 
Study  of  mental  diseases,  34-42 
Stupor,  anergic,  226 
causation  of,  230 
definition  of,  217 
epileptic,  230 
melancholic,  220 
paralytic,  230 
prognosis  in,  230 
secondary,  229 
treatment  of,  230 
varieties  of,  219 
Suicidal  impulse,  247 

frequency  of,  110 
melancholia,  104 
Suicide,  a  determined,  108 
case  of,  217 
in  an  epileptic,  294 
letter  of  a,  108 

modes  of  committing,  105-107 
Sunstroke  a  cause  of  insanity,  298 
Suspicion,  monomania  of,  196 
Sydenham  on  insanity  from  ague,  417 
Symptomatological  classification,  44 
Syphilis,  its  prevalence,  301 
Syphilitic  insanity,  302 

cephalalgia  in,  309 
delusional,  303 
pathology  of,  304,  308,  311 
prognosis  in,  311 
secondary,  302 
syphilomatous,  304,  307 
treatment  of,  309 
vascular,  304 


TEMPERAMENTS,  doctrine  of,  39 
melancholic,  55 
sanguine,  123 
Temperature,  in  children,  123 
in  insanity,  49 
in  mania,  128,  141 
in  puerperal  insanity,  356 
Tennessee,  laws  respecting  insane,  520 
Tests  of  insanity  made  by  lawyers,  428 
Texas,  laws  respecting  insane,  522 
Traumatic  idiocy,  300 
insanity,  298 

prevalence  of,  300 
trephining  in,  299 
Tuke,  D.  Hack,  on  stupor,  218 
Tuke,  J.  Batty,  his  statistics  of  puerperal 
insanity,  359 
on  lactational  insanity,  362 
Tumors  of  brain  and  insanity, -281 
Twins,  with  hereditary  neurosis,  168 


UNCONTROLLABLE  impulse,  231 
United   States,   laws   respecting   in- 
sane, 541 
Utah,  laws  respecting  insane,  524 


VASO-MOTOR  spasm,  102 
Vermont,    laws    respecting    insane, 
526 
Verriicktheit  primare,  135,  259 
Visceral  melancholia,  74 

pathology  of  (Plate  VII.  Fig.  1), 
82 
Volitional  insanity,  231 


WASHINGTON,  laws   respecting    in- 
sane, 531 
West  Virginia,  laws    respecting   insane, 

533 
Wilkes  on  insanity  from  Bright's  disease, 
414 
on  svphilitic  aflFections,  301 
Will-making,  429 

Wisconsin,  laws  respecting  insane,  535 
Wyoming,  laws  respecting  insane,  539 


YELLOWLEES,  D.,  his  case  of  homi- 
cidal mania,  163 
his  case  of  somnambulism,  422 


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talent  for  terse  and  graphic  description  stand  out  with 
undiminished  prominence  in  this  edition.     The  colored 


illustrations  are  admirable  in  execution,  and  well  cal- 
culated to  aid  in  the  elucidation  of  the  text.  The  work 
as  it  now  stands,  is  beyond  peradventure  destined  to 
maintain,  for  many  years  to  come,  its  position  as  one  of 
the  foremost  medical  books  in  any  language. — New 
York  Medical  Journal ,  March  29,  3884. 


A  System  of  Snrgery:  Pathological,  Diagnostic,  Therapeutic  and  Opera- 
tive. By  S.  D.  Gross,  M.D.,  LL.D.,  D.C.L.  Oxon.,  LL.  D.  Cantab.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia.  Sixth  edition, 
thoroughly  revised  and  greatly  improved.  In  two  large  and  beautifully  printed 
imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  ;gi5.oo  ;  half  Russia,  raised  bands,  $16.00. 

We  regard  Gross'  System  of  Surgery  not  only  as  a 
singularly  rich  storehouse  of  scientific  information,  but 
as  marking  an  epoch  in  the  literary  history  ot  surgery. 
The  present  edition  has  received  the  most  careful 
revision  at  the  hands  of  the  eminent  author  himself, 
assisted  in  various  instances  by  able  specialists  in  various 
branches.     All  departments  of  the  vast  and   ever  in- 


creasing literature  of  the  science  have  been  drawn  upon 
for  their  most  recent  expressions.  The  late  advances 
made  in  surgical  practice  have  been  carefully  noted. 
In  every  respect  the  work  reflects  lasting  credit  on 
American  medical  literature. — Medical  and  Surgical 
Reporter,  Nov.  ii,  1882. 


A  Practical  Treatise  on  Fractures.    By  Lewis  a:  Stimson,  b.a.,  m.d., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York, 
Surgeon  and  Curator  to  Bellevue  Hospital,  Surgeon  to  the  Presbyterian  Hospital, 
New  York,  etc.  In  one  very  handsome  octavo  volume  of  598  pages,  with  360 
beautiful  illustrations.     Cloth,  $4.75  ;  leather,  $5.75. 

The  author  gives  in  clear  language  all  that  the  prac-  |  diction  is  simple,  clear  and  vivid.  Wherever  desirable, 
tical  surgeon  need  know  of  the  science  of  fractures,  brief  clinical  histories  are  introduced,  which,  being 
their  etiology,  symptoms,  process  of  unijn  and  treat-  \  skilfully  chosen  to  illustrate  particular  points,  attest  the 
ment,  according  to  the  latest  developments.  A  thorough  rich  experience  of  the  author.  The  numerous  beauti- 
explanation  of  the  pathological  anatomy  and  a  careful  fully  executed  illustrations  form  an  especial  attraction 
description  of  the  various  methods  of  procedure  make  of  the  book. — Centralblatt  fur  Chirurgie ,  May  19, 
the   book  full  of  value  for    every    practitioner.     The     1883. 


The  Topographical  Anatomy  of  the  Brain.    By  John  c.  Dalton.  m.d., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York.  In 
one  very  handsome  quarto  volume  of  about  200  pages  of  descriptive  text,  with 
forty-nine  life-size  photographic  plates  of  Brain  Sections,  and  a  like  number  of 
outline  explanatory  plates,  as  well  as  many  carefully  executed  woodcuts  through  the 
text.     Shortly. 

HENRY  C.  LEA'S  SON  &  CO.,  PHILADELPHIA. 


Illnstrations  of  the  Inflnence  of  the  Mind  npon  the  Body  in  Health  and 

Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  By  Daniel  Hack 
TuKE,  M.D.,  Joint  Author  of  the  Manual  of  Psychological  Medicine,  etc.  New- 
edition.  Thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of 
467  pages,  with  two  colored  plates.      Cloth,  $3.00.    Just  Ready. 

In  all  medicine  that  pertains  to  psychological  subjects  tion  We  heartily  wish  this  volume  could  find  a  place 
no  one  occupies  a  more  exalted  position  than  the  well-  in  every  physician's  library,  for  here  may  be  found  a 
known  author  of  this  volume.  His  investigations  in  physiological  explanation  of  many  perplexing  phe- 
regard  to  mental  phenomena  always  command  atten-  :  nomena. — Cincinnati  Lancet  and  Clinic,  ^la.t.  2g,i?S,^. 


Preventive    Medicine.     By  B.  W.    Richardson,    M.A.,   M.  D.,  LL.  D., 

F.R.S.,  F.S.A.,  Fellow  of  the  Royal  College  of  Physicians,  London.  In  one  octavo 
volume  of  729  pages.  Cloth,  $4.00;  leather,  ^5.00;  very  handsome  half  Russia, 
raised  bands,  $5.50.    Just  Ready. 

The  volume  before  us  is  a  classical  production,  com-  ;  of  its  kind  that  has  ever  been  published.  It  is  scientific, 
prehensive  in  scope,  logical  m  arrangement,  rich  in  ;  methodical  and  practical.  The  time  of  its  publication 
material,  sound  in  doctrine,  and  instructive  in  its  is  most  opportune — The  Medical  A^eivs,  March  22, 
teachings.      This  book,  taken  as  a  whole,  is  the  best  '  1884. 


Legal  Medicine.  By  Charles  Meymott  Tidy,  M.B.,  F.C.S.,  Professor 
of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital, 
etc.  Volume  II.  Legitimacy  and  Paternity,  Pregnancy,  Abortion,  Rape,  Indecent 
E.xposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia,  Drowning,  Hanging, 
Strangulation,  Suffocation.  Making  a  very  handsome  imperial  octavo  volume  of 
529  pages.     Cloth,  $6.00;  leather,  1:7.00.    Just  Ready. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.     Cloth,  $6.00 ;  leather,  $7.00.     Recently  Issued. 

He  whose  inclinations  or  necessities  lead  him  to  as-  l  due  attention  to  the  most  recent  advances  in  medical 
sume  the  functions  of  a  medical  jurist  wants  a  book  '  science.     Mr.  Tidy's  work  bids  fair  to  meet  this  need 
encyclopaedic  in  character,  in  which  he  may  be  reason-  |  satisfactorily. — Boston  Medical  and  Surgical  Journal, 
ably  sure  of  finding  medico-legal  topics  discussed  with  '  February  8,  1883. 
judicial  fairness,  with  sufficient  completeness,  and  with  ' 


Nervous  Diseases;  Their  Description  and  Treatment.  By  Allan  McLane 
H.A.MILTOX,  M.D.,  Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics, 
Blackwell's  Island,  N.  Y.,  and  at  the  Out-Patients'  Department  of  the  New  York 
Hospital.  Second  edition,  thoroughly  revised  and  rewritten.  In  one  octavo  volume 
of  598  pages,  with  72  illustrations.     Cloth,  $4.00. 

When  the  first  edition  of  this  good  book  appeared  we  best  of  its  kind  in  any  language,  which  is  a  handsome 
gave  it  our  emphatic  endorsement,  and  the  present  endorsement  from  an  exalted  source.  The  improve- 
edition  enhances  our  appreciation  of  the  book  and  its  ments  in  the  new  edition,  and  the  additions  to  it,  will 
author  as  a  safe  guide  to  students  of  clinical  neurology,  justify  its  purchase  even  by  those  who  possess  the  old. 
One  of  the  best  and  most  critical  of  English  neurologi-  — Alienist  and  Neurologist,  April,  1882. 
cal  journals.  Brain,  has  characterized  this  book  as  the  < 


A  System  of  Midwifery,  including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  By  William  Leishman,  M.D.,  Regius  Professor  of  Midwifery  in 
the  University  of  Glasgow,  etc.  Third  American  edition,  revised  by  the  Author,  with 
additions  by  John  S.  Parry,  M.D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc. 
In  one  large  and  very  handsome  octavo  volume  of  740  pages,  with  205  illustrations. 
Cloth,  $4.50;  leather,  $5.50;  very  handsome  half  Russia,  raised  bands,  $6.00. 


To  the  American  student  the  work  before  us  must 
prove  admirably  adapted.  Complete  in  all  its  parts, 
essentially  modem  in  its  teachings,  and  with  demon- 
strations noted  for  clearness  and  precision,  it  will  gain 


in  favor  and  be  recognized  as  a  work  of  standard 
merit.  The  work  cannot  fail  to  be  popular  and  is 
cordially  recommended. — Neiv  Orleans  Medical  and 
Surgical  Journal,  March,  1880. 


A  Practical  Treatise  on  Diseases  of  the  Skin.    For  the  use  of  Students 

and  Practitioners.  By  J.  Nevins  Hyde,  A.M.,  M.D.,  Professor  of  Dermatology  and 
Venereal  Diseases  in  Rush  Medical  College,  Chicago.  In  one  handsome  octavo 
volume  of  570  pages,  with  66  beautiful  and  elaborate  illustrations.  Cloth,  $4.25  ; 
leather,  $5.25. 

The  author  has  given  the  student  and  practitioner  a  ;  to  our  literature  and  a  reliable  guide  to  students  and 
work  admirably  adapted  to  the  wants  of  each.  We  ^  practitioners  in  their  studies  and  i^xAcnce..— American 
can  heartily  commend  the  book  as  a  valuable  addition    Journal  of  the  Medical  Sciences,  July,  1883. 


HENRY  C.  LEAS  SON  &  CO.,  PHILADELPHIA. 


HENRY  C.  LEA'S   S0:N^  &  CO.'S 

(LATE  HENRY  C.   LEA) 

CLASSIFIED    CATALOGUE 

O  F 

MEDICAL  AND  SUEGICAL 

PUBLICATIONS. 


In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following  pages, 
the  publishers  would  state  that  no  pains  are  spared  to  secure  a  continuance  of  the  confi- 
dence earned  for  the  publications  of  the  house  by  their  careful  selection  and  accuracy  and 
finish  of  execution. 

The  large  nwmber  of  inquiries  received  from  the  profession  for  a  finer  class  of  bindings  than  is 
usually  placed  on  medical  books  has  induced  us  to  put  certain  of  our  standard  publications  in 
half  Mussia;  and,  that  the  growing  taste  may  be  encouraged,  the  prices  have  been  fixed  at  so  small 
an  advance  over  the  cost  of  sheep  as  to  place  it  within  the  means  of  all  to  possess  a  library  that 
shall  have  attractions  as  well  for  the  eye  as  for  the  mind  of  the  reading  practitioner. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works  not 
kept  in  stock.  Where  access  to  bookstores  is  not  convenient,  books  will  be  sent  by  mail 
postpaid  on  receipt  of  the  price,  and  as  the  limit  of  mailable  weight  has  been  removed,  no 
difficulty  will  be  experienced  in  obtaining  through  the  post-office  any  work  in  this  cata- 
logue. No  risks,  however,  are  assumed  either  on  the  money  or  on  the  books,  and  no  pub- 
lications but  our  own  are  supplied,  so  that  gentlemen  will  in  most  cases  find  it  more  con- 
venient to  deal  witli  the  nearest  bookseller. 

A  handsomely  illustrated  catalogue  will  be  sent  to  any  address  on  receipt  of  a  three-cent 
stamp. 

HENRY   C.  LEA'S  SON  &  CO. 

No8.  706  and  708  Sansom  St.,  Philadelphia,  April,  1884. 


PROSPECTUS    FOR    1884. 

A   WEEKLY    MEDICAL   JOURNAL. 


SUBSCRIPTION    RATES. 

The  Medical  News         .         .        .         .         .         .  .       FiveDollars. 

The  Americas  Journal  of  the  Medical  Sciences         .       FiveDollars. 

COMMUTATION    RATES. 

The  Medical  News  "I      Nine  Dollars  per 

The  American  Journal  of  the  Medical  Sciences   J      annum,  in  advance. 

THE  MEDICAL  NEWS. 

A  National  Weekly  Medical  Periodical,  containing-  28  to  32  Quarto 
Pagres  of  Reading  Matter  in  Each  Issue. 

In  making  the  change,  two  years  since,  from  a  monthly  to  a  weekly,  tliose  in  cliarge 
of  The  Medical  News,  proposed  to  furnish  the  profession  what  it  had  never  before 
enjoyed — a  journal  national  in  the  widest  sense  of  the  word,  devoted  to  the  highest  ideals 
of  professional  morals  and  honor,  an  unsparing  enemy  of  quackery  and  fraud,  a  scientific 
magazine  in  elaboration,  and  a  newspaper  in  energy  and  vitality.  They  believe  that  in 
every  respect  it  has  fulfilled  its  promises.  Its  readers  and  contributors  are  found  in  every 
State  and  Territory ;    its  Editorial  Staff  includes  some  of  the  brightest  minds  in  the 


Henry  C.  Lea's  Son  &  Co.'s  Publications — The  Medical  News. 


profession,  and  in  every  issue  living  topics  are  editorially  discussed  in  a  scholarly  and  prac- 
tical manner ;  its  corps  of  qualified  reporters  and  correspondents  covers  all  the  medical 
centres  of  both  hemispheres,  and  secures  for  its  columns  the  earliest  information  on 
matters  of  medical  interest,  and  its  reports  of  Medical  Progress  are  culled  from  all  the 
important  professional  journals  published  on  both  continents.  In  short,  its  unrivaled 
organization  enables  The  News  each  week  to  lay  upon  the  table  of  its  readers  an  epit- 
ome of  a  week's  advance  of  the  whole  medical  world. 

The  News,  always  endeavoring  to  enhance  its  usefulness,  has  pleasure  in  announcing  to 
the  profession  that  arrangements  have  been  perfected  for  the  publication  during  this 
year  of  a  highly  valuable  series  of  practical  articles  by  eminent  men  on  the  more  im- 
portant diseases  met  with  by  every  practitioner  in  his  daily  duties.  The  following  gentle- 
men have  kindly  promised  to  aid  in  carrying  out  this  plan,  and  the  eminence  of  their 
names  is  a  guarantee  of  the  value  of  the  papers  to  be  contributed  by  them. 


D.  HAYES  AGNEW,  Philadelphia. 
HARRISON  ALLEN,  Philadelphia. 
I.  E.  ATKINSON,  Baltimore. 
ROBERTS  BARTHOLOW,  Philadelphia. 
S.  M.  BEMISS,  New  Orleans. 
L.  DUNCAN  BULKLEY,  New  York. 
CHARLES  H.  BURNETT,  Philadelphia. 
SAMUEL  C.  BUSEY,  Washington. 
WILLIAM  H.  BYFORD,  Chicago. 
P.  S.  CONNER,  Cincinnati. 
J.  M.  DA  COSTA,  Philadelphia. 
FREDERIC  S.  DENNIS,  New  York. 
FRANK  DONALDSON,  Baltimore. 
LOUIS  A.  DUHRING,  Philadelphia. 
ROBERT  T.  EDES,  Boston. 
J.  FERGUSON,  Toronto. 
AUSTIN  FLINT,  New  York. 
WILLIAM  GOODELL,  Philadelphia. 
SAMUEL  D.  GROSS,  Philadelphia. 
«AMUEL  W.  GROSS,  Philadelphia. 
J.  F.  HEUSTIS,  Mobile,  Ala. 
WILLIAM  HUNT,  Philadelphia. 
JOSEPH  C.  HUTCHISON,  Brooklyn. 
JAMES  NEVINS  HYDE,  Chicago. 
A.  REEVES  JACKSON,  Chicago. 
EDWARD  W.  JENKS,  Chicago. 
A.  F.  A.  KING,  Washington. 
GEORGE  M.  LEFFERTS,  New  York. 
WILLIAM  T.  LUSK,  New  York. 
JOHN  M.  MACKENZIE,  Baltimore. 
HUNTER  McGUIRE,  Richmond. 


RICHARD  McSHERRY,  Baltimore. 
THOMAS  M.  MARKOE,  New  York. 
S.  WEIR  MITCHELL,  Philadelphia. 
THOMAS  G.  MORTON,  Philadelphia. 
L.  S.  McMURTRY,  Danville,  Ky. 
WILLIAM  F.  NORRIS,  Philadelphia. 
WILLIAM  OSLER,  Montreal. 
FESSENDEN  N.  OTIS,  New  York. 
ALONZO  B.  PALMER,  Ann  Arbor,  Mich. 
ROSWELL  PARK,  Buffalo. 
THEOPHILUS  PARVIN,  Philadelphia. 
WILLIAM  PEPPER,  Philadelphia. 
F.  PEYRE  PORCHER,  Charleston. 
THADDEUS  A.  REAMY,  Cincinnati. 
J.  C.  REEVE,  Dayton,  O. 
LEWIS  A.  SAYRE,  New  York. 
FRANCIS  J.  SHEPHERD,  Montreal. 
STEPHEN  SMITH,  New  York. 
J.  LEWIS  SMITH,  New  York. 
LEWIS  A.  STIMSON,  New  York. 
ROBERT  W.  TAYLOR,  New  York. 
WILLIAM  THOMSON,  Philadelphia. 
L.  McLANE  TIFFANY,  Baltimore. 
JAMES  TYSON,  Philadelphia. 
ELY  VAN  DE  WARKER,  Syracuse,  N.  T. 
J.  COLLINS  WARREN,  Boston. 
ROBERT  F.  WEIR,  New  York. 
JAMES  T.  WHITTAKER,  Cincinnati. 
EDWARD  WIGGLESWORTH,  Boston. 
E.  WILLIAMS,  Cincinnati. 
DAVID  W.  YANDELL,  Louisville. 


Original  articles  from  foreign  authorities  may  also  be  expected,  the  first  of  which 
appeared  in  the  issue  of  January  5th,  1884,  on  Digital  Exploration  of  the  Bladder 
IN  Obscure  Vesical  Diseases,  with  its  results,  by  Sir  Henry  Thompson,  of  London, 
Surgeon  Extraordinary  to  the  King  of  the  Belgians,  etc.,  with  7  original  illustrations. 
From  the  high  character  of  the  articles  already  published,  a  fair  conception  may  be 
formed  of  the  value  of  the  series  to  every  professional  man  in  active  practice. 

In  typographical  appearance,  The  News  of  1884  shows  an  advance  even  upon 
the  issues  of  1882-83,  and  nothing  has  been  left  undone  to  economize  the  time  and  promote 
the  comfort  of  its  readers.  It  appears  in  a  double-columned  quarto  form,  printed  by  the 
latest  improved  Hoe  speed  presses,  on  handsome  paper,  from  a  clear,  easily  read  type, 
specially  cast  for  its  use. 

The  Medical  News  employs  all  the  approved  methods  of  modem  journalism  with 
the  intention  of  rendering  itself  indispensable  to  the  profession ;  and,  in  the  anticipation  of 
an  unprecedented  circulation,  its  subscription  has  been  placed  at  the  exceedingly  low  rate 
of  $5  per  annum,  in  advance.  At  this  price  it  ranks  as  the  cheapest  medical  periodical 
in  this  country,  and  when  taken  in  connection  with  The  American  Journal  at  NINE 
DOLLARS  per  annum,  it  is  confidently  asserted  that  a  larger  amount  of  material  of  the 
highest  class  is  offered  than  can  be  obtained  elsewhere,  even  at  a  much  higher  price. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Am.  Journ.  Med.  Sci.    3 

THE  AMERICAN  JOURNAL  of  the  MEDICAL  SCIENCES, 

Edited  by  I.  MINIS  HAYS,  A.  M.,  M.  D., 

Is  published  Quarterly,  on  the  first  days  of  January,  April,  July 

and  October,  each  Number  containing  over  Three  Hundred 

Octavo  Pages,  fully  Illustrated. 

Founded  in  1820,  The  American  Journal  entered  with  1884  upon  its  sixty-fifth 
consecutive  year  of  faithful  and  honorable  service  to  the  profession.  Being  the  only 
periodical  in  the  English  language  capable  of  presenting  elaborate  articles — the  form  in 
which  the  most  important  discoveries  have  always  been  communicated  to  the  profession — 
The  American  Journal  cannot  fail  to  be  of  the  utmost  value  to  physicians  who  would 
keep  themselves  au  eourant  with  the  medical  thought  of  the  day.  It  may  justly  claim  that 
it  numbers  among  its  contributors  all  the  most  distinguished  members  of  the  profession, 
that  its  history  is  identified  with  the  advances  of  medical  knowledge,  and  that  its  circu- 
lation is  co-extensive  with  the  use  of  the  English  language. 

During  1884  The  Journai-  will  continue  to  present  those  features  which  have  long 
proved  so  attractive  to  its  readers. 

The  Original  Department  will  consist  of  elaborate  and  richly  illustrated  articles 
from  the  pens  of  the  most  eminent  members  of  the  profession  in  all  parts  of  the  country. 

The  Review  Department  will  maintain  its  well-earned  reputation  for  discernment 
and  impartiality,  and  will  contain  elaborate  reviews  of  new  works  and  topics  of  the  day, 
and  numerous  analytical  and  bibliographical  notices  by  competent  writers. 

Following  these  comes  the  Quarterly  Summiary  of  Improvements  and  Dis- 
coveries in  the  Medical  Sciences,  which,  being  a  classified  and  arranged  condensation 
of  important  articles  appearing  in  the  chief  medical  journals  of  the  world,  furnishes  a 
compact  digest  of  medical  progress  abroad  and  at  home. 

Tlie  subscription  price  of  The  American  Journal  op  the  Medicai.  Sciences  has 
never  been  raised  during  its  long  career.  It  is  still  sent  free  of  postage]_for  Five  Dollars 
per  annum  in  advance. 

Taken  together,  the  Journal  and  News  combine  the  advantages  of  the  elaborate  prep- 
aration that  can  be  devoted  to  a  quarterly  with  the  prompt  conveyance  of  intelligence 
by  the  weekly;  while,  by  special  management,  duplication  of  matter  is  rendered  im- 
possible. 

It  will  thus  be  seen  that  for  the  very  moderate  sum  of  NINE  DOLLARS  in  advance 
the  subscriber  will  receive  free  of  postage  a  weekly  and  a  quarterly  journal,  both  reflecting 
the  latest  advances  of  the  medical  sciences,  and  containing  an  equivalent  of  more  than  4000 
octavo  pages,  stored  with  the  choicest  material,  original  and  selected,  that  can  be  furnished 
by  the  best  medical  minds  of  both  hemispheres.  It  would  be  impossible  to  find  elsewhere 
so  large  an  amount  of  matter  of  the  same  value  offered  at  so  low  a  price. 

H^^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn  to 
the  order  of  the  undersigned ;  where  these  are  not  accessible,  remiKances  for  subscrip- 
tions may  be  made  at  the  risk  of  the  publishers  by  forwarding  in  registered  letters.  Address, 
Henry  C.  Lea's  Son  &  Co.,  Nos.  706  and  708  Sansom  St.,  Philadelphia. 


*  ^  *  Communications  to  both  these  periodicals  are  invited  from  gentlemen  in  all  parts 
of  the  country.  Original  articles  contributed  exclusively  to  either  periodical  are  liberally 
paid  for  upon  publication.  When  necessary  to  elucidate  the  text,  illustrations  Avill  be  fur- 
nished without  cost  to  the  author. 

All  letters  pertaining  to  the  Editorial.  Department  of  The  Medical  News  and  The 
American  Journal  of  the  Medical  Sciences  should  be  addressed  to  the  Editorial 
Offices,  1004  Walnut  Street,  Philadelphia. 

All  letters  pertaining  to  the  Business  Department  of  these  journals  should  be  addressed 
exclvMvdy  to  Henry  C.  Lea's  Son  &  Co.,  706  and  708  Sansom  Street,  Philadelphia. 


4  Henry  C.  Lea's  Son  &  Co.'s  Publications — Dictionaries. 

nVNGLISON,  HOBLJET,  M.I)., 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON;  A  Dictionary  of  Medical  Science :  Containing 
a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Tlierapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulfe  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terras, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  A  new  edition,  thoroughly  revised,  and  very  greatly  modified  and 
augmented.  By  Richard  J.  Duxglisox,  M.  I).  In  one  very  large  and  handsome  royal 
octavo  volume  of  1139  pages.  Cloth,  $(5.50;  leather,  raised  bands,  $7.50;  very  handsome 
half  Russia,  raised  bands,  $8. 

The  object  of  the  author,  from  the  outset,  has  not  been  to  make  the  work  a  mere  lexi- 
con or  dictionary  of  terms,  but  to  afford  imder  each  word  a  condensed  view  of  its  various 
medical  relations,  and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of 
medical  science.  Starting  with  this  view,  the  immense  demand  which  has  existed  for  the 
work  has  enabled  him,  in  repeated  revisions,  to  augment  its  completeness  and  usefulness, 
until  at  length  it  has  attained  the  position  of  a  recognized  and  standard  authority  wherever 
the  language  is  spoken.  Special  pains  have  been  taken  in  the  preparation  of  the  present 
edition  to  maintain  this  enviable  reputation.  The  additions  to  the  vocabulary  are  more 
numerous  than  in  any  previous  revision,  and  particular  attention  has  been  bestowed  on  the 
accentuation,  which  will  be  found  marketl  on  every  word.  The  typographical  arrangement 
has  been  greatly  improved,  rendering  reference  much  more  easy,  and  every  care  has  been 
taken  with  the  mechanical  execution.  The  volume  now  contains  the  matter  of  at  least 
four  ordinary  octavos. 

A  book  of  which  every  American  ought  to  be  j  work  has  been  well  known  for  about  lorty  years, 
proud.  When  the  learned  author  of  the  work  [  and  needs  no  words  of  praise  on  our  part  to  recom- 
passed  away,  probably  all  of  us  feared  lest  the  book  j  mend  it  to  the  members  of  the  medical,  and  like- 
should  not"  maintain  its  place  in  the  advancing  j  wise  of  the  pharmaceutical,  profession.  The  latter 
science  whose  terms  it  defines.  Fortunately,  Dr.  especially  are  in  need  of  a  work  which  gives  ready 
Richard  .1.  Dunglison,  having  assisted  hisfatlierin  |  and  reliable  information  on  thousands  of  subjects 
the  revision  of  several  editions  of  the  work,  and  I  and  terms  which  they  are  liable  to  encounter  in 
having  been,  therefore,  trained  in  the  methods  pursuing  their  daily  vocations,  but  with  which  they 
and  imbued  with  the  spirit  of  the  book,  has  been  j  cannot  be  expected  to  be  familiar.  The  work 
able  to  edit  it  as  a  work  of  the  kind  should  be  !  before  us  fully  supplies  this  want. — American  Jour^ 
edited — to  carry  it  on  steadily,  without  jar  or  inter-  |  nal  of  Phamiacy,  Feb.  1874. 

ruption,  along  the  grooves  of  thought  it  has  trav-  ■  Particular  care  has  been  devoted  to  derivation 
elled  during  its  lifetime.  To  show  the  magnitude  |  and  accentuation  of  terms.  With  regard  to  the 
of  the  task  which  Dr.  Dunglison  has  assumed  and  ^  latter,  indeed,  the  present  edition  mav  be  consid- 
carried  through,  it  is  only  neces.sary  to  state  that  I  ered  a  complete  "Pronouncing  Dictionary  of 
more  than  six  thousand  new  subjects  have  been  j  Medical  Science."  It  is  perhaps  the  most  reliable 
added  in  the  present  edition. — Philadelphia  Medical  I  work  published  for  the  busy  practitioner,  as  itcon- 
Tivies,  Jan.  3, 1874.  I  tains  information  upon  every  medical  subject,  in 

About  the  first  book  purchased  by  the  medical  \  *  ^P^Z  f'"'  "[f^^y  "^cess  and  with  a  brevity  as  ad- 
student  is  the  Medical  Dictionary,  The  lexicon  |  mirable  as  it  is  practical.-^outAem  J/e<i.<;ai  iiecord, 
explanatorvof  technical  terms  is  simply  a  sine  7ua  !  ^^."- ^^''*-  ,      ,.    .  ,  ,,     ,  ,        ., 

non.  In  a  science  so  extensive  and  with  such  col-  1  A  valuable  dictionary  of  the  terms  employed  in 
laterals  as  medicine,  it  is  as  much  a  necessity  also  I  medicine  and  the  allied  sciences,  and  of  the  relar 
to  the  practising  physician.  To  meet  the  wants  of  I  tions  of  the  subiects  treated  under  each  head.  It 
students  and  most  p"hvsicians  the  dictionary  must  j  well  deserves  the  authority  and  popularity  it  has 
be  condensed  while  comprehensive,  and  practical  j  obtained.— fin^i«A  Med.  Jour.,  Oct.  31, 1874. 
while  perspicacious.  It  was  because  Dunglison's  !  Few  works  of  this  class  exhibit  a  grander  monu- 
met  these  indications  that  it  became  at  once  the  !  ment  of  patient  research  and  of  scientific  lore.— 
dictionary  of  general  use  wherever  medicine  was  j  London  Lancet,  May  13, 1875. 

studied  in  the  English  language.  In  no  former  Dunglison's  Dictionary  is  incalculably  valuable, 
revision  have  the  alterations  and  additions  been  and  indispensable  to  every  practitioner  of  medi- 
so  great.    The  chief  terms  have  been  set  in  black  I  cine,   pharmacist  and  dentist.— IFestem    Laiuxt, 


letter,  while  the  derivatives  follow  in  small  caps ; 
an  arrangement  which  greatly  facilitates  reference. 
—Cincinnati  Lancet  and  Clinic,  Jan.  10,  1874. 

As  a  standard  work  of  reference   Dunglison's 


March,  1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  e:[tent  ol 
references. — London  Medical  Gazette. 


HOBLYN,  BICJBEAItn  D.,  M.  2). 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 
Sciences.  Revised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.     Cloth,  $1.50;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table — Southern 
Medical  and  Surgical  JoumaL  

BOD  WELL,  G.  F.,  F.  B.  A.  S.,  F.  C.  S., 

Lecturer  on  yatural  Science  at  Clifton  College,  England. 

A  Dictionary  of  Science :  Comprising  Astronomy,  Chemistry,  Dynamics,  Elec- 
tricity, Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism,  Mechanics,  Meteorology, 
Pneumatics,  Sound  and  Statics.  "  Contributed  bv  J.  T.  Bottomlev,  M.  A.,  F.  C.  S.,  William 
Crookes,  F.R.S.,  F.C.S.,  Frederick  Guthrie,  B'A.,  Ph.  D.,  R.  A.  Proctor,  B.A.,  F.R.A.S, 
G.  F.  Rodwell,  Editor,  Charles  Tomlinson,  F.R.S.,  F.C.S.,  and  Richard  Wornell,  M.A., 
B.Sc.  Preceded  by  an  Essay  on  the  History  of  the  Physical  Sciences.  In  one  handsome 
octavo  volume  of  702  pages,  with  143  illustrations.     Cloth,  $5.00. 


The  work  is  intended  as  an  aid  to  the  medical 
student,  and  as  such  appears  to  fulfil  admirably  its 
object  by  its  excellent  arrangement,  the  full  com- 
pilation" of  facts,  the  perspicuity  and  terseness  of 
language,  and  the  clear  and  instructive  illustra- 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Gompends,  Anat.        5 
HARTSHORNE,  HENRY,  A,  31,,  M.  !>., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thorouglily  revised  and  greatly  improved.  In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.     Cloth,  §4.25;  leather,  §5.00. 

its  due  share  of  attention.  We  can  conceive  such 
a  work  to  be  useful,  not  only  to  students,  but  to 
practitioners  as  well.  It  reflects  credit  upon  the 
industiy  and  energy  of  its  able  editor. — Boston 
Medical  and  Surfjical  Journal,  Sept.  3,  1874. 
tions.— .4OTe7-i<:n»i  Journal  of  Pharmacy,  July,  1874.  I  -We  can  sav,  with  the  strictest  truth,  that  it  is  the 
The  object  of  this  manual  is  to  afford  a  conven-  |  best  work  of  the  kind  with  which  we  areacquainl- 
lent  work  of  reference  to  students  during  the  brief  !  ed.  It  embodies  in  a  condensed  form  all  recent 
moments  at  their  command  while  in  attendance  contributions  to  practical  medicine,  and  is  there- 
upon medical  lectures.  It  is  a  favorable  sign  that  fore  useful  to  every  busy  practitioner  tliroughout 
it  has  been  found  necessary,  in  a  short  space  of  our  country,  besides  being  admirably  adapted  to 
time,  to  issue  a  new  and  carefully  revised  edition,  the  use  of  students  of  medicine.  The  book  is 
The  illustrations  are  very  numerous  and  unusu-  [  faithfully  and  ably  executed. — Charleston  Medical 
ally  clear,  and  each  part  seems  to  have  received  i  Journal.  April,  1875. 

STUDENTS'  SERIES  OF  MANUALS, 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine 
and  Surgery.  They  will  be  written  by  eminent  Teacliers  or  Examiners,  and  will  be 
issued  in  pocket-size  12rao.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price. 
The  following  volumes  may  now  be  announced :  Klein's  Elements  of  Histology,  Pepper's 
Surgical  Pathology,  Treves,'  Surqical  Applied  Anatomy,  R.a.lfe's  Clinical  Chemistry,  Clakkb 
and  Lockwood's  Dissector^  Manual,  and  Power's  Human  Physiology,  {Just  ready) ; 
EoBERTSOx's  Physical  Physiologi/,  Bruce's  Materia  Medica  aiid  Therapeutics,  Bellamy's 
Operative  Surgery,  and  Bell's  Comparative  Physiology  and  Anatomy,  [In  active  preparation 
for  early  publication.)     For  separate  notices  see  index  on  last  page. 

NEILL,  JOHN,  31,  n,,  ^nd  S3IITH,  F,  G,,  31,  J),, 

Late  Surgeon  to  the  Pcnna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Vniv.  of  Penna. 

An  Analytical  Compendium  of  the  "Various  Branches  of  Medical 
Science,  for  the  use  and  examination  of  Students.  A  new  edition,  revised  and  improved. 
In  one  very  large  royal  12mo.  volume  of  974  pages,  with  374  woodcuts.  Cloth,  $4;  strongly 
bound  in  leather,  raised  bands,  $4.75. 


LUDLOW,  J,  L.,  31,  ID,, 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 
A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.  To  which 
is  added  a  Meilical  Formulary.  Tliird  edition,  thoroughly  revised,  and  greatly 'extended 
and  enlarged.  In  one  handsome  roval  12mo.  volume  of  816  large  pages,  with  370  illus- 
trations.    Cloth,  $3.25 ;  leather,  $3.7o. 

The  arrangement  of  tliis  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 

WILSON,  ERAS31US,  F,  R,  S, 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  W.  H. 
GoBRECHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Cloth,  $4.00;  leather,  $5.00. 

S31ITH,  H,  H,,  M.  D„  and  HORNER,  W3I,  E.,3I,I),, 

Emeritus  Prof,  of  Surgery  in  the  Univ.  of  Penna.,  etc.        Late  Prof,  of  Anat.  in  the  Univ.  of  Penna. 
An  Anatomical  Atlas,  Illustrative  of  the  Structure  of  the  Human  Body.     In  one 
large  imperial  octavo  volume  of  200  pages,  with  634  beautiful  figures.      Cloth,  1^50. 

CLELAND,  JOHN,  31,  H,,  F,  R.  S,, 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Galway. 

A  Directory  for  the  Dissection  of  the  Human  Body.     In  one  12mo. 

volume  of  178  pages.     Cloth,  $1.25. 

BELLA3IY,  EDWARD,  F,  R,  C,  S,, 

Senior  Assistant-Surgeon  to  the  Charing-Cross  Hospital,  London, 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Regions  of  the  Human  Body,  and  intendwi  as  an  Introduction  to 
Operative  Surgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 

HARTSHORNE'S   HANDBOOK   OF   .A.NATOMY  |  HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
AND  PHY.SIOLOGY.    Second  edition,  revised.        OGY.    Eighth  edition,  extensively  revised  and 

In  one  royal  12mo.  volume  of  310  pages,  with  220  I      modified.    In  two  octavo  volumes  of  1007  pages, 

woodcuts.    Cloth,  $1.75.  i      with  320  woodcuts.    Cloth,  $6.00. 


6  Henry  C.  Lea's  Son  &  Co.'s  Publications — Anatomy. 

ALLEW,  SAItltlSOJV,  M.  D., 

Professor  of  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  Witli  an  Intro- 
ductory Chapter  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to  the 
Philadelphia  Hospital.  In  one  large  and  handsome  quarto  volume  of  about  700  double- 
columned  pages,  Tvith  380  illustrations  on  109  lithographic  plates,  many  of  which  are  in 
colors,  and  about  150  engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section 
I.  Histology  {Just  ready).  Section  II.  Bones  and  J  oints  {Just  ready).  Section  HI. 
Muscles  and  Fascia-  {Just  ready).  Section  IV.  Arteries,  Veins  and  Lymphatics 
{Jv^Ht  ready).  Section  V.  Nervous  System  {Just  ready).  Section  VI.  Organs  of 
Sense,  of  Digestion  and  Genito-Urinary  Organs  {In  press).  Price  per  Section, 
$3.50.     For  sale  by  subscription  only.     Apply  to  the  Publishers 

Extract  from   Introduction. 

It  is  the  design  of  this  book  to  present  the  facts  of  human  anatomy  in  the  manner  best 
suited  to  the  requirements  of  the  student  and  the  practitioner  of  medicine.  The  author 
believes  that  such  a  book  is  needed,  inasmuch  as  no  treatise,  as  far  as  lie  knows,  contains,  in 
addition  to  the  text  descriptive  of  the  subject,  a  systematic  presentation  of  such  anatomical 
facts  as  can  be  applied  to  practice. 

A  book  which  will  be  at  once  accurate  in  statement  and  concise  in  terms ;  which  will  be 
an  acceptable  expression  of  the  present  state  of  the  science  of  anatomy ;  which  will  exclude 
nothing  that  can  be  made  applicable  to  the  medical  art,  and  which  will  thus  embrace  all 
of  surgical  importance,  while  omitting  nothing  of  value  to  clinical  medicine, — would  appear 
to  have  an  excuse  for  existence  in  a  country  where  most  surgeons  are  general  practitioners, 
and  where  tliere  are  few  general  practitioners  who  have  no  interest  in  surgery. 

Among  other  mattei-s,  tlie  b<wk  will  be  found  to  contain  an  elaborate  description  of  the 
tissues;  an  account  of  the  normal  development  of  the  body;  a  section  on  the  nature  and 
varieties  of  monstrosities ;  a  section  on  the  method  of  conducting  post-mortem  examina- 
tions ;  and  a  section  on  the  study  of  the  superficies  of  the  body  taken  as  a  guide  to  the 
position  of  the  deeper  structures.  These  will  appear  in  their  appropriate  places,  duly 
subordinated  to  the  design  of  presenting  a  text  essentially  anatomical. 

A  book  like  this  is  an  ideal  rarely  realized.  It  I  brought  to  it  a  mind  well  prepared  for  the  task  by 
is  a  mine  of  wealth  in  the  informationit  gives.  It  ]  extensive  reading,  critical  judgment  and  literaiy 
diflers  from  all  preceding  anatomies  in  its  scope,  j  ability.  We  can  cordially  recommend  the  work 
and  XH,  we  believe,  a  vast  miprovement  upon  them  I  to  the  profession,  believing  that  it  is  suited  not 
all.  The  chief  novelty  about  the  book,  and  really  j  only  to  those  of  scientific  tastes,  but  that  it  will  be 
one  of  the  greatest  neeas  in  anatomy,  is  the  ex-  of  use  to  the  practising  physician. — Boston  Medical 
tension  of  the  text  to  cover  not  only  anatomical  and  Surgical  Journal,  Jan.  11,  1883. 
descriptions,  but  the  uses  of  anatomy  in  studying        it  is  to  be  considered  a  study  of  applied  anatomy 


disease.  This  is  done  by  stating  the  narrower 
topographical  relations,  and  also  the  wider  clin- 
ical relations,  of  the  more  remote  parts,  by  giving 
a  brief  account  of  the  uses  of  the  various  organs, 
and  by  qftoting  cases  which  illustrate  the  "local- 
ization of  diseased  action."    The  plat«s  are  beau- 


in  its  widest  sense — a  systematic  presentation  of 
such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgery.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 


tiful  specimens  of  work  by  one  who  long  smce  sidered  a  dry  subject.  The  department  of  Histol 
won  a  deserved  reputation  as  an  SLrtist— The  Mcdt-  \  ogy  is  treated  in  a  masterly  manner,  and  the 
cal  ^ews,  October  21, 1882.  I  ground  is  travelled  over  by  one  thoroughly  famil- 

Tlie  appearance  of  the  book  marks  an  epoch  in  i  lar  with  it  The  illustrations  are  made  with  great 
medical  literature.  It  is  the  first  important  work  I  care,  and  are  simply  superb.  It  would  be  impos- 
on  human  anatomy  that  has  appeared  in  America;  |  sible,  except  in  a  general  way,  to  point  out  the 
and,  more  than  this,  its  scope  is  new  and  original.  1  excellence  of  the  work  of  the  author  in  the  second 
it  i^  intended  to  be  both  descriptive  and  topograph-  Section — that  devoted  to  the  consideration  of  the 
ical,  scientific  and  practical,  so  that  while  satisfy-  Bones  and  Joints.  There  is  as  much  of  practical 
ing  the  anatomist  it  will  be  of  value  to  the  practis-  j  application  of  anatomical  points  to  the  every-day 
ing  physician.  The  names  of  the  parts,  muscular  i  wants  of  the  medical  clinician  as  to  those  of  the 
attachments,  etc.,  are  printed  either  on  the  figure  |  operating  surgeon.  In  fact,  few  general  practi- 
or  close  beside,  so  that  they  are  easily  recognized,  tioners  will  read  the  work  without  a  feeling  of  sur- 
The  illustrations  made  from  the  author's  dissec-  prised  gratification  that  so  many  point.s,  concem- 
tions  deserve  the  highest  praise.  They  are  well  con-  ing  which  they  may  never  have  thought  before, 
ceived  and  well  executed,  handsome  artistically  are  so  well  presented  for  their  consideration.  It 
and  clear  anatomically.  As  the  author  points  out,  is  a  work  which  is  destined  to  be  the  best  of  ita 
such  a  work  as  he  has  undertaken  Is  necessarily  kind  in  any  language. — Medical  Record,  Nov.  25, '82. 
encyclopsedic,  and  the  result  shows  that  he   has  | 


CLABKE,W,B.,F.B,C,S.  &  LOCKWOOn,C,B„F.R,C.S. 

Demonstrators  of  Anatomy  at  St.  Bartholometc^s  Hospital  Medical  School,  London. 
The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49   illustrations.     Limp   cloth,   red  edges,   $1.50.      Just  ready.     See  Students^  Series  of 
Manuals,  page  5. 

This  is  a  very  excellent  manual  for  the  use  of  the    part,  are  good  and  instructive.    The  book  is  neat 
student  who  desires  to  learn  anatomy.   The  meth-    and  convenient.    We  are  glad  to  recommend  it — 
ods  of  demonstration  seem  to  us  very  satisfactory.    Boston  Medical  and  Surgical  Journal,  Jan.  17, 1884. 
There  are  many  woodcuts  which,  for  the  most 


TBBVJES,  FBEDEBICK,  F,  B.  C,  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 
Applied  Anatomy.  In  one  pocket-size  12mo.  volume  of  540  pages,  with  61  illus- 
trations. Limp  cloth,  red  edges,  $2.00.  Just  ready.  See  Students' Series  of  Manuuis,  Tpage  5. 
He  has  produced  a  work  which  will  command  a  I  quickened  by  daily  use  as  a  teacher  and  practi- 
larger  circle  of  readers  than  the  class  for  which  it  I  tioner,  has  enabled  our  author  to  prepare  a  work 
was  written.  This  union  of  a  thorough,  practical  |  which  it  would  be  a  mosl  difficult  task  to  excel. — 
acquaintance  with  these  fundamental   branches,  |  The  American  Practitioner,  Feb.,  1884. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Anatomy.  7 

GMAY,  JSEIirBY,  F,  B.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London. 

Anatomy",  Descriptive  and  Surgical.  The  Drawings  by  H.  V.  Carter,  M.  D., 
and  Dr.  Westmacott.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With 
an  Introduction  on  General  Anatomy  and  Development  by  T,  Holmes,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  K.  C.  S.,  Surgeon  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Koyal  College  of 
Surgeons  of  England.  A  new  American  from  the  tenth  enlarged  and  improved  London 
edition.  To  which  is  added  the  second  American  from  the  latest  English  edition  of 
Landmarks,  Medical  and  Surgical,  by  Luther  Holden,  F.  11.  C.  S.,  author  of 
"Human  Osteology,"  "A  Manual  of  Dissections,"  etc.  In  one  imperial  octavo  volume 
of  1023  pages,  with  564  large  and  elaborate  engravings  on  wood.  Cloth,  $6.00 ;  leather, 
$7.00 ;  very  handsome  half  Russia,  raised  bands,  |7.50.     Just  ready. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  of 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and 
splendid  series,  which  will  greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy, 
and  will  also  serve  to   refresh  the  memory  of  those  who  may  find  in  the  exigencies  of 

Sractice  the  necessity  of  recalling  the  details  of  the  dissecting-room.  Combining,  as  it 
oes,  a  complete  Atlas  of  Anatomy  with  a  thorough  treatise  on  systematic,  descriptive 
and  applied  Anatomy,  the  work  will  be  found  of  great  service  to  all  physicians  who  receive 
students  in  their  offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the 
groundwork  of  a  thorough  medical  education. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  w<is  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by 
type  and  illustration  in  anatomical  study. 


This  well-known  work  comes  to  us  as  the  latest 
American  from  the  tenth  English  edition.  As  its 
title  indicates,  it  has  passed  tlirough  many  hands 
and  has  received  many  additions  and  revisions. 
The  work  is  not  susceptible  of  more  improvement. 
Taking  it  all  in  all,  its  size,  manner  of  make-up, 
its  character  and  illustrations,  its  general  accur- 
acy of  description,  its  practical  aim,  and  its  per- 
spicuity of  style,  it  is  tlje  Anatomy  best  adapted  to 
the  wants  of  the  student  and  practitioner. — Medical 


Record,  Sept.  15, 1883.  1  1, 1883. 


There  is  probably  no  work  used  so  universally 
by  physicians  and  medical  students  as  this  one. 
It  is  (Reserving  of  the  confidence  that  they  repose 
in  it.  If  the  present  edition  is  compared  with  that 
issued  two  years  ago,  one  will  readily  see  how 
much  it  has  been  improved  in  that  time.  Many 
pages  have  been  added  to  the  text,  especially  in 
those  parts  that  treat  of  histology,  and  many  new 
cuts  have  been  introduced  and  old  ones  ijriodified. 
— Journal  of  the  American  Medical  Association,  Sept. 


Also  fob  sale  separate — 
HOLJDBl^,  LVTHER,  F.  JR.  O.  S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London. 
Landmarks,  Medical  and  Surgical.    Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.     In  one  handsome  12mo.  volume  of  148  pages.     Cloth,  $1.00. 


This  little  book  is  all  that  can  be  desired  within 
its  scope,  and  its  contents  will  be  found  simply  in- 
valuable to  the  young  surgeon  or  physician,  since 
they  bring  before  him  sucn  data  as  he  requires  at 
every  examination  of  a  patient.  It  is  written  in 
language  so  clear  and  concise   that   one    ought 


almost  to  learn  it  by  heart.  It  teaches  diagnosis  by 
external  examination,  ocular  and  palpable,  of  the 
body,  with  such  anatomical  and  physiological  facts 
as  directly  bear  on  the  subject.  It  Is  eminently 
the  student's  and  young  practitioner's  book. — Phy- 
sician and  Surgeon,  Nov.  1881. 


DALTOW,  JOHN  a,  M.  />., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 

The  Topographical  Anatomy  of  the  Brain.  In  one  very  handsome  quarto 
volume  of  about  200  pages  of  descriptive  text.  Illustrated  with  forty-nine  life-size  photo- 
graphic illustrations  of  Brain  Sections,  with  a  like  number  of  outline  explanatory  plates, 
as  well  as  many  carefully-executed  woodcuts  through  the  text.     In  press. 

ELLIS,  GFOBGF  VIJS^FJR, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  From  the  eighth  and  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.    Cloth,  $4.25 ;  leather,  $5.25. 


Ellis'  Demonstrations  is  the  favorite  text-book 
of  the  English  student  of  anatomy.  In  passing 
through  eight  editions  it  has  been  so  revised  and 
adapted  to  the  needs  of  the  student  that  it  would 
Beem  that  it  had  almost  reached  perfection  in  this 


special  line.  The  descriptions  are  cleat,  and  the 
methods  of  pursuing  anatomical  investigations  are 
given  with  such  detail  that  the  book  is  honestly 
entitled  to  its  name. — St.  Louis  Clinical  Record, 
June,  1879. 


8 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Physiologry. 


D ALTON,  JOHN  C,  31,  !>., 

Professor  of  Physioloqii  in  the  Colleqe  of  Physicians  and  Surgeons,  Neio  York,  etc. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  vohime  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00  ;  leather,  $6.00 ;  very  handsome  half  Russia,  raised  bands,  16.50. 


The  merits  of  Professor  Dalton's  text-book,  his 
Bmooth  and  pleasing  style,  the  remarkable  clear- 
ness of  his  descriptions,"  which  leave  not  a  chapter 
obscure,  his  cautious  judgment  and  the  general 
correctness  of  his  facts,  are  perfectly  known.  They 
have  made  his  text-book  the  one  most  familiar 
to  American  students. — Med.  Record,  March  4,  1882. 

Certainly  no  physiological  work  has  ever  issued 
from  the  press  that  presented  its  subject-matter  in 
a  clearer  and  more  attractive  light.  Almost  every 
page  bears  evidence  of  the  exhaustive  revision 
hat  has  taken  place.  The  material  is  placed  in  a 
more  compact  form,  yet  its  delightful  charm  is  re- 
tained, and  no  subject  is  thrown  into  obscurity. 
Altogether  this  edition  is  far  in  advance  of  any 


previous  one,  and  will  tend  to  keep  the  profession 
posted  as  to  the  most  recent  additions  to  our 
physiological  knowledge. — Michiqan  Medical  News, 
April,  1882. 

One  can  scarcely  open  a  college  catalogue  that 
does  not  have  mention  of  Dalton's  Physiology  as 
the  recommended  text  or  consultation-book.  For 
American  students  we  would  unreservedly  recom- 
mend the  edition  of  Dr.  Dalton's  work  now  before 
us.  Let  it  suffice  to  state  that  revisions  have  been 
made  to  such  an  extent  as  to  bring  the  volume  as 
fully  up  to  the  present  state  of  physiological  knowl- 
edge as  it  is  practicable  for  any  author  of  a  book 
to  do. —  Virginia  Medical  Monthly,  July,  1882. 


FOSTER,  3IICHAEL,  M,  D.,  F.  M.  S., 

Professor  of  Physiology  in  Cambridge  University,  England. 

Text-Book  of  Physiology.     Second  American  from  the  third  English  edition. 

Edited,   with   extensive   notes  and  additions,   by  Edward  T.    Eeichert,   M.  D.,   late 

Demonstrator  of  Experimental  Therapeutics  in  the  University  of  Pennsylvania.     In  one 

handsome  royal  12mo.  volume  of  999  pages,  with  259  illusl.     Cloth,  $3.25;  leather,  $3.75. 


A  more  compact  and  scientific  work  on  physiol- 
ogy has  never  been  published,  and  we  believe  our- 
selves not  to  be  mistaken  in  asserting  that  it  has 
now  been  introduced  into  every  medical  college 
in  which  the  English  language  is  spoken.  This 
work  conforms  to  the  latest  researches  into  zoology 
and  comparative  anatomy,  and  takes  into  consid- 
eration the  late  discoveries  in  physiological  chem- 
istry and  the  experiments  in  localization  of  Ferrier 
and  others.  The  arrangement  followed  is  such  as 
to  render  the  whole  subject  lucid  and  well  con- 
nected in  its  various  parts. — Chicago  Medical  Jour- 
nal and  Examiner,  August,  1882. 


Dr.  Miciiael  Foster's  Manual  of  Physiology  has 
been  translated  into  the  German,  with  a  preface, 
by  Professor  Kiihne.  Kiihne  points  out  in  his 
preface  tiiat  the  abundant  material,  in  spite  of  the 
moderate  size,  is  not  condensed  to  systematic 
shortness,  but  the  whole  is  related  in  a  narrative 
style.  Tlie  translation  of  it  into  German  is  a  well- 
merited  compliment,  since  Germany  is  the  es- 
pecial home  of  physiology,  and  its  literature  is 
abundantly  rich  in  text-books,  monographs  and 
periodicals  on  physiology. — American  Medical  Bi- 
weekly, June  18, 1881. 


FOWFM,  HENRY,  31,  B„  F.  R,  C,  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.      In  one  handsome  pocket-size  12mo.  volume  of  396  pages, 
with  47  illustrations.     Cloth,  $1.50.     Just  ready.     See  Students'  Series  of  Manuals,  page  6. 


This  little  work  is  deserving  of  the  highest 
praise,  and  we  can  hardly  conceive  how  the  main 
facts  of  this  science  could  have  been  more  clearlv 
or  concisely  stated.    The  price  of  the  work  is  such 


as  to  place  it  within  the  reach  of  all,  while  the  ex- 
cellence of  its  text  will  certainly  secure  for  it  most 
favorable  commendation. — Cincinnati  Lancet  and 
Clinic,  Feb.  IG,  1884. 


ROBERTSON,  J,  3IcGREGOR,  31.  A,,  31,  B,, 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physical  Physiology.  In  active  preparation.  See  Students'  Series  of  Manuals,  page  5. 

BELL,  F.  JEFFREY,  31,  A,, 

Professor  of  Comparative  Anatomy  at  King's  College,  London. 

Comparative  Physiology  and  Anatomy.     In  active  preparation  for  early 

publication.     See  Students'  Series  of  Manuals,  page  5. 

CARPENTER,  W3I,  B,,  31,  D,,  F,  R,  S,,  F,  G,  S.,  F.  L,  S,, 

Registrar  to  the  University  of  London,  etc. 

Principles  of  Human  Physiology.  Edited  by  Henry  Poaver,  M.  B.,  Lond., 
F.  R.  C.  S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  A  new  American  from  the 
eighth  revised  and  enlarged  edition,  with  notes  and  additions  by  Francis  G.  Smith,  M.  D., 
late  Professor  of  the  Institutes  of  Medicine  in  the  University  of  Pennsylvania.  In  one 
very  large  and  handsome  octavo  volume  of  1083  pages,  with  two  plates  and  373  illus- 
trations Cloth,  $5.50 ;  leather,  $6.50 ;  half  Russia,  $7. 
The  editors  have,  with  their  additions  to  the     tion.    We  have  been  agreeably  surprised  to  find 


only  work  on  physiology  in  our  language  that,  in 
the  fullest  sense  of  the  word,  is  the  production  of 
a  philosopher  as  well  as  a  physiologist,  brought  it 
up  fully  to  the  standard  of  our  knowledge  of  its 
subject  at  the  present  day.  The  additions  by  the 
American  editor  give  to  the  work  as  it  is  a  consid- 
erable value  beyond  that  of  the  last  English  edi- 


the  volume  so  complete  in  regard  to  the  structure 
and  functions  of  the  nervous  system  in  all  its  rela- 
tions— a  subject  that  in  many  respects  is  one  of 
the  most  difficult  of  all,  in  the  whole  range  of 
physiology,  upon  which  to  produce  a  full  and  satis- 
factory treatise  of  the  class  to  which  the  one  be- 
fore us  belongs.— J^/.o/A'erv.  and  Ment.  Bis.,  Apr.,'77. 


CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  or  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  a  preface  by  D.  F.  Condie,  M.  D.,  and 
explanations  of  scientific  words.  In  one  small 
12mo.  volume  of  178  pages.    Cloth,  CO  cents. 


lehmann's  manual  of  chemical  phys- 
iology. Translated  from  the  Geiman  with 
notes  and  additions,  by  J.  Cheston  Mobkis,  M.  D. 
In  one  octavo  volume  of  327  pages,  with  41  illus- 
trations.   Cloth,  $2.25. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Chemistry. 


ATTFIBLJy,  JOHJSf,  Ph,  !>., 

Professor  of  Practical  Chcviistry  to  the  Pharviaceutical  Society  of  Crreat  Britain,  etc. 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  tenth 
English  edition,  specially  revised  by  the  Author.  In  one  handsome  royal  12mo.  volume 
of  728  pages,  with  87  illustrations.     Cloth,  $2.50 ;  leather,  $3.00.     Jiist  ready. 

It  is  a  book  on  which  too  much  praise  cannot  be  |  The  clearness,  system  and  thoroughness  of  this 
bestowed.  As  a  text  book  for  medical  schools  it  |  manual  have  made  it  for  the  last  sixteen  years  the 
is  unsurpassable  in  the  present  state  of  clinical  constant  companion  of  the  medical  and  pliarma- 
scienee,  and  having  been  prepared  with  a  special  ceutical  student.  Within  this  time  it  has  under- 
view  towards  medicine  and  pharmacy,  it  is  alike  |  gone  ten  editions,  which  have  progressively  en- 
indispensabie  to  all  persons  engaged  in  those  de-  j  larged  its  scope  and  general  usefulness.  We  again 
partments  of  science.  It  includes  the  whole  |  welcome  the  book,  and  give  it  a  cordial  endorse- 
chemistry  of  the  last  Pharmacopoeia. — Pacific  Medi-  ment. — New  Orleans  Medical  and  Surgical  Journal , 
eal  and  Surgical  Journal,  Jan.  1884.  |  January,  1884. 


BLOXAM,  CHARLES  X., 

Professor  of  Chemistry  in  King's  College,  London. 
Chemistry,  Inorganic   and   Organic.     New  American  from  the  fifth  Lon- 
don  edition,   thoroughly  revised   and  much   improved.     In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $3.75 ;  leather,  $4.75.     Just  ready. 


The  general  plan  of  this  work  remains  the 
same  as  in  previous  editions,  the  evident  object 
being  to  give  clear  and  concise  descriptions  of  all 
known  elements  and  of  their  most  important 
compounds,  with  explanations  of  the  chemical 
laws  and  principles  involved.  We  gladly  repeat 
now  the  opinion  we  expressed  about  a  former 
edition,  that  we  regard  Bloxam's  Chemistry  as 
one  of  the  best  treatises  on  general  and  applied 
chemistry. — American  Jour,  oj  Pharmacy,  Dec.  1883. 

Commentfrom  us  on  thisstandard  work  is  almost 
superfluous.  It  differs  widely  in  scope  and  aim 
from  tiiat  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.  It  adopts  the  most  direct  meth- 
ods in  stating  the  principles,  hypothe.'-es  and  facts 
of  the  science.  Its  language  is  so  terse  and  lucid, 
and  its  arrangement  of  matter  so  logical  in  se- 


quence, that  the  student  never  has  occasion  to 
complain  that  chemistry  is  a  hard  study.  Much 
attention  is  paid  in  this  work  to  experimental 
illustrations  of  chemical  principles  and  phenom- 
ena, and  the  mode  of  conducting  these  experi- 
ments. The  book  maintains  the  position  it  has 
always  held  as  one  of  the  best  manuals  of  general 
chemistry  in  the  English  language. — The  Detroit 
Lancet,  February,  1884. 

This  ample  and  thorough  treatise  on  chemistry 
has  in  this  revision  been  extended  and  brought 
down  to  the  latest  date,  so  as  to  include  a  notice  of 
all  important  recent  discoveries  in  this  progressive 
science.  In  this  edition  the  theoretical  portions 
have  received  especial  attention,  so  as  to  bring 
tliem  into  accordance  with  modern  views. — Med. 
and  Surgical  Reporter,  Dec.  1, 1883. 


BE3ISEN,  IRA,  31,  D.,  JPh.  !>., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore. 
Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.    Second  and  revised  edition.    In  one  handsome  royal  12mo. 
volume  of  240  pages.     Cloth,  $1.75.     Just  ready. 

fo  the  average  text  books  of  the  day. — American 
Journal  of  Science,  March,  1884. 


The  boolc  is  a  valuable  contribution  to  the  chemi- 
cal literature  of  instruction.  That  in  so  few  years 
a  second  edition  has  been  called  for  indicates  that 
many  chemical  teachers  have  been  found  ready 
to  endorse  its  plan  and  to  adopt  its  methods.  In 
this  edition  a  considerable  proportion  of  the  book 
has  been  rewritten,  much  new  matter  has  been 
added  and  the  whole  has  been  brought  up  to  date. 
We  earnestly  commend  this  book  to  every  student 
of  chemistry.  The  high  reputation  of  the  author 
assures  its  accuracy  in  all  matters  of  fact,  and  its 
judicious  conservatism  in  matters  of  theory,  eom- 
oined  with  the  fulness  with  which,  in  a  small 
compass,  tlie  present  attitude  of  chemical  science 
towards  the  constitution  of  compounds  is  con- 
sidered, gives  it  a  value  much  beyond  that  accorded 


We  would  heartily  recommend  it  to  any  student 
who  desires  to  acquaint  himself  with  the  subject. 
In  the  matter  we  can  find  nothing  to  criticise. 
Every  point  is  explained  with  perfect  satisfaction, 
so  that  the  merest  tyro  may  understand. — Physician 
and  Surgeon,  Dec.  1883. 

When  the  first  edition  made  its  appearance,  w« 
welcomed  it  as  a  very  valuable  addition  to  litera- 
ture; the  more  we  have  consulted  it  since  that 
time  the  more  we  have  appreciated  its  value.  The 
book  deserves  to  be  placed  in  the  hands  of  every 
student  of  chemistry. — American  Journal  of  Phar- 
macy, December,  1883. 


FOWWES,  GEORGE,  Fh.  D. 

A  Manual  of  Elementary  Chemistry ;  Theoretical  and  Practical.  Revised 
and  corrected  by  Henry  Watts,  B.  A.,  F.  R.  S.,  Editor  of  A  Dictionary  op  Chemistry, 
etc.  A  new  American  from  the  twelfth  and  enlarged  London  edition.  Edited  by  Robert 
Bridges,  M.  D.  In  one  large  royal  12mo.  volume  of  1031  pages,  with  177  illustrations 
on  wood  and  a  colored  plate.     Cloth,  $2.75  ;  leather,  $3.25. 

of  late  years,  the  chapter  on  the  General  Principles 
of  Chemical  Philosophy  has  been  entirely  rewrit- 
ten. The  latest  views  on  Equivalents,  Quantiva- 
lence,  etc.,  are  clearly  and  fully  set  forth.  This 
last  edition  is  a  great  improvement  upon  its  prede- 
cessors, which  is  saying  not  a  little  of  a  book  that 
has  reached  its  twelfth  edition. — Ohio  Medical  Re- 


The  book  opens  with  a  treatise  on  Chemical 
Physics,  including  Heat,  Light,  Magnetism  and 
Electricity.  These  subjects  are  treated  clearly 
and  briefly,  but  enough  is  given  to  enable  ttie  stu- 
dent to  comprehend  tlie  facts  and  laws  of  Chemis- 
try proper.  It  is  the  fashion  of  late  years  to  omit 
these  topics  from  works  on  chemistry,  but  their 
omission  is  not  to  be  commended.  As  was  required 
by  tlie  great  advance  in  the  science  of  Chemistry 


corder,  Oct.,  1878. 


Wohler's  Outlines  of  Organic  Chemistry.    Edited  by  Fittig.    Translated 
by  Iea  Resisen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.     Cloth,  $3. 


10 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Chemistry. 


HOFFMAJSIS^,  F.,  A,M.,  JPh.n.,  &  FOWEB  F.B.,  Fh,I>,, 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chtm.      Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determin.. ion  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterat■^ns.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 

We  congratulate  the  author  on  the  appearance  full  without  being  redundant,  so  that  the  tyro  can 
of  the  third  edilionof  this  work,  published  for  the  easily  understand  them  and  practise  the  processes 
first  time  in  this  country  also.  It  is  admirable  and  successfully.  The  work  is  thus  well  adapted  as  a 
the  information  it  undertakes  to  supply  is  both  book  of  reference  for  practical  use,  and  calculated 
extensive  and  trustworthy.    The  selection  of  pro-  j  to  impart  such  information  as  in  each  particular 


cesses  for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  tne  descrip- 
tion of  them  singularly  explicit.  Moreover,  it  is 
exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharma- 
ceutical Journal  and  Transactions,  1883. 

Viewed  in  regard  to  its  general  aims  as  well  as 
to  the  manner  in  which  they  have  been  carried 
out,  the  work  will  be  found  as  complete  as  can  well 
be  desired.     The  descriptions  of  operations  are 


case  may  be  useful  or  required  witiiin  the  limit  of 
its  objects. — American  Journal  of  Pliar.,  May,  1883. 
This  work  has  undergone  a  very  considerable 
change  since  the  first  edition  appeared  in  1873; 
in  its  present  form  it  is  a  marked  improvement 
on  the  earlier  editions.  The  authors  are  to  be 
congratulated  on  the  manner  in  which  they  have 
remodelled  the  work ;  in  its  present  form  it  is 
sure  to  prove  a  valuable  aid  in  the  practice  of 
pliarmaceutical  chemistry. —  Land.  Chemist,  and 
Druggist,  June  15, 188,3. 


WATTS,  HFNBT,  B.  A.,  F.  B,  8. 

Author  of  "A  Dictionary  of  Chemistry,"  etc. 

A  Manual  of  Physical  and  Inorganic  Chemistry, 
of  500  pages  with  150  illustrations.    In  press. 


In  one  12mo.  volume 


CLOWES,  FBAJVJK,  1>.  Sc,  London, 

Senior  Science- Master  at  the  High  School,  New  castle-under- Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inoi'ganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Second  American  from  the  third  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  372  pages,  with  47  illustrations.     Cloth,  $2.50. 

The  chief  object  of  the  author  of  the  present  work 
was  to  furnish  one  which  was  sufficiently  elemen- 
tary in  the  description  of  apparatuses,  chemicals. 


modes  of  experimentation,  etc.,  so  as  to  "reduce 
to  a  minimum  tlie  amount  of  assistance  required 
from  a  teacher."  It  is  a  generally  recognized  fact 
that  one  of  the  most  serious  hindrances  to  the 
utility  of  many  of  the  smaller  text-books  is  the  too 
great  conciseness  of  the  language  employed,  which 


renders  it  unintelligible  to  the  primary  student 
unless  supplemented  by  copious  verbal  explana- 
tions from  the  teacher.  The  Elementarji  Treatise 
of  Dr.  Clowes,  examined  with  reference  to  the 
above  claims,  is  found  to  be  a  great  improvement 
on  other  elementary  works.  A  student  who  care- 
fully reads  this  text  will  scarcely  need  the  assist- 
ance of  a  tutor  in  following  out  any  of  the  ex- 
periments described. —  Va.Med.  Monthly, kp.,\iai\. 


BALFE,  CHABLES  S.,  M,  Z>.,  F.  B.  C.  F,, 

Assistant  Physician  at  the  London  Hospital. 
Clinical  Chemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 

See  Stiidents'  Series  of  Maniuds,  page  5. 
cine.    Dr.  Ralfe  is  thoroughly  acquainted  with  the 


illustrations.  Limp  cloth,  red  edges,  $1.50. 
This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the' book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ougnt  to 
know,  of  the  applications  of  chemistry  in  medi- 


latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2, 1884. 


CLASSEN,  ALEXANnEB, 

Professor  in  the  Royal  Polytechnic  Scfwol,  Aix-la-Chapclle. 

Elementary  Quantitative  Analysis.  Translated,  with  notes  and  additions,  by 
Edgab  F.  Smith,  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Pennsylvania.  In  one  handsome  royal  12mo.  volume  of  324  pages,  with  36 
illustrations.     Cloth,  $2.00. 


It  is  probably  the  best  manual  of  an  elementary 
nature  extant,  insomuch  as  its  methods  are  tlie 
best.  It  teaches  by  examples,  commencing  with 
single   determinations,   followed  by  separations, 


and  then  advancing  to  the  analysis  of  minerals  and 
such  products  as  are  met  with  in  applied  chemis- 
try. It  is  an  indispensable  book  for  students  in 
chemistry. — Boston  Journal  of  Chemistry,  Oct.  1878. 


GBEENE,  WLLLIAM  H,,  3L  J>#, 

Demonstrator  of  Chemistry  iji  the  Medical  Department  of  the  University  of  Pennsylvania. 

A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow- 
man's Medicjil  Chemistry.  In  one  i2rao.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 
It  is  a  concise  manual  of  three  hundred  pages,  I  the  recognition  of  compounds  due  to  pathological 
giving  an  excellent  summary  of  the  best  methods  i  conditions.  The  detection  of  poisons  is  treated 
of  analyzing  the  liquids  and  .solids  of  the  body,  both  with  sufficient  fulness  for  the  purpose  of  thestu- 
for  the  estimation  of  their  normal  constituents  and  '  dent  or  practitioner. — Boston  Jl.  of  Chem.,June,  '80. 


A    MANUAL   OF    QUALITATIVE    ANALYSIS.  I  Loudon  edition.    In  one  royal  12mo.  volume,  witb 
By  Robert  Galloway,  F.  C.  S.     From  the  sixth  |  illustrations.    Preparing. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Pharm.,  Mat.  Med.     11 
BARRISH,  BJDWAni), 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmaof. 

A  Treatise  on  Pharmacy :  designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Pliysician  and  Pharmaceutist.  With  many  Formulse  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand,  Ph.  G.  In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.  Cloth,  $5  ;  leather,  $6.  Just  ready. 
From  the  Preface  to  the  Fifth  Edition. 
A  nevr  edition  of  Mr.  Parrish's  standard  work  has  been  rendered  an  imperative  necessity, 
not  only  by  the  late  revision  of  the  U.  S.  Pharmacopceia,  but  also  by  the  great  advance  in 
chemical  and  pharmaceutical  science  within  the  last  decade.  The  changes  thus  required 
have  rendered  the  task  of  the  editor  by  no  means  light,  and  have  considerably  increased 
the  size  of  the  volume,  in  spite  of  earnest  efforts  at  condensation  and  the  omission  of  all 
o.bsolete  matter.  The  new  preparations  of  the  Pharmacopceia  have  been  introduced,  to- 
gether with  its  tests  for  chemical  and  officinal  compounds,  and  its  system  of  parts  by  weight 
in  place  of  definite  quantities.  The  entire  chemical  section  has  been  rearranged  in  con- 
formity with  the  present  views  of  that  science,  and  the  subject  of  testing,  both  qualitative 
and  quantitative,  has  been  rendered  as  complete  as  the  scope  of  the  work  would  permit  and 
the  wants  of  students  are  likely  to  reqviire.  All  genei-al  pharmaceutical  and  chemical  pro- 
cesses have  been  arranged  in  a  separate  part,  thus  facilitating  reference  and  avoiding 
repetition,  while  special  apparatus  for  particular  classes  of  preparations  has  been  placed 
under  those  classes.  Tlie  syllabi,  whicli  proved  so  valuable  a  feature  of  previous  editions, 
and  on  which  Professor  Maisch  bestowed  so  much  care,  have  been  retained;  many  of  them 
have  been  rewritten  and  new  ones  introduced.  All  new  remedies  of  interest  have  been 
added,  and  in  the  chapter  on  elixirs  some  new  formulae  of  nuich  popularity  have  been 
given.  The  editor  need  only  add  that  he  has  spared  no  labor  or  care  in  the  hope  of  ren- 
dering the  work  as  acceptable  as  it  has  hitherto  been  to  the  student  and  the  pharmaceutist. 


This  well-known  work  presents  itself  now  based 
upon  the  recently  revised  new  PharmacopcEia. 
Several  important  modifieations  of  the  internal 
arrangement  have  been  made,  and  we  believe 
they  will  be  found  to  increase  the  practical  use- 
fulness of  the  book.  Each  page  bears  evidence  of 
the  care  bestowed  upon  it,  and  conveys  valuable 
information  from  the  rich  store  of  the  editor's 


experience.  In  fact,  all  that  relates  to  practical 
pharmacy — apparatus,  processes  and  dispensing — 
has  been  arranged  and  described  with  clearnesa 
in  its  various  aspects,  so  as  to  afford  aid  and  advice 
alike  to  the  student  and  to  the  practical  pharma- 
cist. The  work  is  judiciously  illustrated  with  good 
woodcuts — American  Journal  of  Pharmacy,  Janu- 
ary, 1884. 


HERMAJ^W,  Dr.  i.. 

Professor  of  Physiology  in  the  University  of  Zurich. 

Experimental  Pharmacology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
extensive  additions,  by  Robert  Meade  Smith,  ISI.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.     Cloth,  |1.50.     Just  ready. 


The  selection  of  animals  and  their  management, 
the  paths  of  elimination  and  changes  of  poisons 
in  the  body,  the  explanation  of  the  symptoms  pro- 
duced by  poisons,  alterations  in  tissue,  in  the  re- 
productive function  and  in  temperature,  action  on 
muscles  and  in  nerves,  anatomical  and  chemical 
changes  produced  bj'  poisons,  all  are  successively 
passed  in  review  in  a  practical  instructive  fashion, 
which  speaks  well  for  both  the  author  and  the 
translator.  The  book  is  deserving  of  an  enco- 
mium as  a  correct  exponent  of  the  spirit  and 
tendencies  of  modern  pharmacological  research. 


After  closely  perusing  the  pages,  all  laden  to  over- 
flowing with  tlie  richest  facts  of  physiological  in- 
vestigation, and  after  following  the  astounding 
progress  of  toxic  pharmacology  as  revealed  by  the 
author,  we  feel  that  we  are  fast  approaching  the 
realization  of  that  Utopian  dream  in  which  we 
behold  experimental  and  clinical  experience 
firmly  and  inseparably  united.  It  is  a  reliable, 
concise  and  practical  vade  mecum  for  tlie  time- 
pressed  worker  in  the  laboratory. — New  Orleans 
Medical  and  Surgical  Journal,  May,  1883. 


MAISCH,  JOJIJS^M.,  Phar.  !>., 

Professor  of  Blateria  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.     For  the  use  of  Students,  Druggists,  Pharmacists 
and    Physicians.     New   edition.     In   one    handsome    royal   12mo.  volume.     Preparing. 
A  few  notices  of  the  previous  edition  are  appended. 


_A  book  evidently  written  for  a  purpose,  and  not 
simply  for  the  purpose  of  writing  a  book.  It  is 
comprehensive,  as  it  refers  to  all,  or  nearly  all, 
that  is  of  essential  value  in  organic  materia  medica. 


clear  and  simple  in  its  style,  concise,  since  it  would 
be  difficult  to  find  in  it  a  superfluous  word,  and  yet 
sufficiently  explicit  to  satisfy  the  most  critical. — 
Chicago  Med.  Jnl.  and  Exam.,  Aug.  1882. 


J>  UJARI>IN-BBA  UMETZ, 

Member  of  the  Academy  of  Medicine,  Physician  to  the  H6pital  St.  Antoine,  Paris. 

Dictionary  of  Therapeutics,  Materia  Medica,  Pharmacology,  Tox- 
icology and  Mineral  Waters.     Translated  with  notes  and  additions.     Preparing. 

GRIFFITH,  ROBERT  FGIESFIELD,  M.  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  John  M.  Maisch, 
Phar.  D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  38  illustrations.     Cloth,  $4.50 ;  leath  er,  $5.50. 


12     Henry  C.  Lea's  Son  &  Co.'s  Publications — Mat.  Med.,  Therap. 


STILLE,  A,,  M.D.,ZL.I>,,  &  MAISCH,  J,  M,,Phar.J)., 

Professor  of  the  Theory  and  Practice  of  Prof  of  Mat.  Med.  and  Botany  in  Phila. 

Medicine  and  of  Clinical  Medicine  in  the  Collec/e  of  Pharmacfi,SecUito  the  Anierir- 

University  of  Pennsylvania.  can  Pharmaceutical  Association. 

The  National  Dispensatory :  Containing  the  Natural  History,  Chemistry,  Pliar- 
macy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  Pliarmacopceias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  references  to  the  French 
Codex.  Third  edition,  thoroughly  revised  and  greatly  enlarged.  In  one  magnificent 
imperial  octavo  volume  of  about  1800  pages,  with  several  hundred  fine  engravings.    In  press. 

Tlie  publishers  have  much  pleasure  in  announcing  to  the  Medical  and  Pharmaceutical 
Professions  that  a  new  edition  of  this  important  work  is  in  press,  and  that  it  will  appear 
in  the  shortest  time  consistent  with  the  care  requisite  for  printing  a  work  of  innuense 
detail,  where  absolute  accuracy  is  of  such  supreme  importance.  Besides  its  revision  on 
the  bfisis  of  the  U.  S.  Pharmacopoeia  of  1880,  it  will  include  all  the  advances  made  in  its 
department  during  the  period  elapsed  since  the  preparation  of  that  work.  To  this  end  all 
recent  medical  and  pharmaceutical  literature,  both  domestic  and  foreign,  has  been  thor- 
oughly sifted,  and  everything  that  is  new  and  important  has  been  introduced,  together 
with  the  results  of  original  investigations.  To  accord  with  the  new  Pharmacopoeia  the 
oflacinal  formula?  are  given  in  parts  by  weight,  but  in  every  instance,  for  the  sake  of  con- 
venience, the  same  proportions  are  also  expressed  in  ordinary  weights  and  measures.  The 
Therapeutical  Index  has  been  enlarged  so  that  it  contains  about  8000  references,  arranged 
under  an  alphabetical  list  of  diseases,  thus  placing  at  the  disposal  of  the  practitioner,  in  tlie 
most  convenient  manner,  the  vast  stores  of  therapeutical  knowledge  constantly  needed  in 
his  daily  practice.  The  work  may  therefore  be  justly  regarded  as  a  complete  Encyclo- 
paedia of  Materia  Medica  and  Therapeutics,  including  1883. 

The  exhaustion  of  tAvo  very  large  editions  of  The  National  Dispensatory  since 
1879  is  the  most  conclusive  testimony  as  to  the  necessity  which  demanded  its  preparation 
and  to  tlie  admirable  manner  in  which  that  duty  has  been  performed.  In  tliis  revision 
tlie  authors  have  sought  to  add  to  its  usefulness  by  including  everything  properly  coming 
within  its  scope  which  can  be  of  use  to  the  physician  or  pharmacist  and  at  the  same  time 
by  the  utmost  conciseness  and  by  the  omission  of  all  obsolete  matter  to  prevent  undue 
increase  in  the  size  of  the  volume.  No  care  will  be  spared  by  the  publishei-s  to  render 
its  typographical  execution  worthy  of  its  wide  reputation  and  universal  use  as  the 
tandard  authority. 

FAMQVHARSOJS^,  ItOBBRT,  31,  !>., 

Lecturer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Third  American  edition, 
specially  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia  by 
Frank  Woodbury,  M.  D.    In  one  handsome  12mo.  volume  of  524  pages.     Cloth,  $2.25. 


Dr.  Farquharson's  Therapeutics  is  constructed 
upon  a  plan  which  brines  before  the  reader  all  the 
essential  points  with  reference  to  the  properties  of 
drugs.  It  impresses  these  upon  him  in  such  a  way 
as  to  enable  him  to  take  a  clear  view  of  the  actions 
of  medicines  and  the  disordered  conditions  in 
which  they  must  prove  useful.  The  double-col- 
umned pages— one  side  containing  the  recognized 
physiological  action  of  the  medicine,  and  the  other 


the  disease  in  which  observers  (who  are  nearly  al- 
ways mentioned)  have  obtained  from  it  good  re- 
sults— make  a  very  good  arrangement.  The  early 
chapter  containing  rules  for  prescribing  is  excel- 
lent. We  have  much  pleasure  in  once  more  draw- 
ing attention  to  this  valuable  and  well-digested 
book,  and  predict  for  it  a  continued  successful  ca- 
reer.— Canada  Med.  and  Surg.  Journal,  Dec.  1882. 


BRVWTOW,  T.  LAUDJEJR,  31.  D., 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  etc. 

A  Manual  of  Materia  Medica  and  Therapeutics,  including  the  Pharmacy, 
the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs.  In  one  handsome  octavo 
volume.     In  press. 

BRUCE,  J,  MITCHELL,  31.  D.,  F.  B.  C.  P. 

Materia  Medica  and  Therapeutics.  In  active  preparation  for  early  publication. 
See  Students'  Series  of  Manuals,  page  5. 

STILLE,  ALEBED,  M.  J>.,  LL.  D., 

professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 

Therapeutics  and  Materia  Medica.  A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description  and  History.  Fourtli  edition, 
revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes,  containing  1936  pages. 
Cloth,  $10.00;  leather,  $12.00;  very  handsome  half  Eussia,  raised  bands,  $13.00. 


The  rapid  exhaustion  of  three  editions  and  the 
universal  favor  with  which  the  work  has  been  re- 
ceived by  the  medical  profession  are  sufficient 
proof  of  Its  excellence  as  a  repertory  of  practical 
and  useful  information  for  the  physician.  The 
edition  before  us  fully  sustains  this  verdict. — 
American  Journal  of  Pharmacy,  Feb.  1875. 

We  can  hardly  admit  that  it  has  a  rival  in  the 


multitude  of  its  citations  and  the  fulness  of  its 
research  into  clinical  liistories,and  wemustassign 
it  a  place  in  the  physician's  library;  not,  indeed, 
as  fully  representing  the  present  state  of  knowledge 
in  pharmacodynamics,  but  as  by  far  the  most  com- 
plete treatise  upon  the  clinical  and  practical  side 
of  tlie  question. — Boston  Medical  and  Surgical  Jour- 
nal, Nov.  5,  1874. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Therap.,  Pathol.,  Histol.    13 


COATS,  JOSEPH,  M.  J).,  JP.  F,  JP.  S,, 

Pothulof/ist  to  the  Glasgow  Western  Infirmary. 

A  Treatise  on  Pathology.    In  one 

with  339  beautiful  illustrations.  Cloth,  $5.50 
The  work  before  us  treats  the  subject  of  Path-  I 
ology  more  extensively  than  it  is  usually  treated  I 
in  similar  works.  Medical  students  as  well  as  \ 
physicians,  who  desire  a  work  for  study  or  refer-  I 
enee,  that  treats  the  subjects  in  the  various  de-  | 
partments  in  a  very  thorough  manner,  but  without 


prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  "any  with  which  we  are  acquainted.  It  sets 
forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,   the  changes  from  a  normal 


very  handsome  octavo  volume  of  [829  pages, 
;  leather,  $6.50.  Just  ready. 
condition  effected  in  structures  by  disease,  ^nnd 
points  out  the  characteristics  of  various  morbid 
agencies,  .«o  that  they  can  be  easily  recognized.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.  There  is  nothing  belonging  to  its  de. 
partment  of  medicine  that  is  not  as  fully  elucidated 
as  our  present  knowledge  will  admit.— Cinannoti 
Medical  Keu-s,  Oct.  1883. 


WOODHEAJD,  G.  SI3IS,  M.  D.,  F,  B.  C.  F.  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 

Practical  Pathology,  A  Manual  for  Students  and  Practitioners.  In  one  very 
beautiful  octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.  Cloth, 
$6.00.     Just  ready. 


It  cannot  often  be  said  in  these  days  of  literary 
activity,  that  a  book  meets  a  distinct  want,  that  it 
opens  "up  new  ground,  and  that  it  is  sure  to  be 
largely  in  request.  All  these  things  are  perfectly 
true  of  tjie  admirable  and  handsome  volume  before 
us.  It  is  literally  the  first  thorough  attempt  to  deal 
fully  with  the  subject  of  practical  pathology,  es- 
pecially in  its  histological  aspect,  and  in  manner 
and  scope  it  stands  alone.  The  va.st  majority  of  the 
figures  interpolated  in  the  text  are  colored,  and 
colored  so  as  to  reproduce  with  tolerable  exactitude 
the  appearances  of  sections  stained  with  various 


reagents.  We  have  formed  a  very  high  opinion  of 
this  work,  and  we  candidly  admit  that  tliere  is  in 
it  little  to  which  exception  could  possibly  be  taken. 
It  is  manifestly  the  product  of  one  who  has  him- 
self travel  led  over  the  whole  field  and  who  is  ski  I  led 
not  merely  in  the  art  of  liistology,  but  in  the  ob.'-er- 
vation  and  interpretation  of  morbid  changes.  The 
work  is  sure  to  command  a  wide  circulation.  It 
should  do  much  to  encourage  the  pursuit  of  path- 
ology, since  such  advantages  in  histological  study 
have  never  before  been  offered. — The  Lancet,  Jan. 
5, 1884. 


CORJSTL,  v.,  and  BAWFIER,  i.. 

Prof,  in  the  Faculty  of  Med.  of  Paris.  Prof,  in  the  College  of  France. 

A  Manual  of  Pathological  Histology.  Translated,  with  notes  and  additions, 
by  E.  O.  Shakespeare,  M.  D.,  Pathologist  and  Ophthalmic  Surgeon  to  Philadelphia 
Hospital,  and  by  J.  Henry  C.  Simes,  M.  I).,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.  In  one  very  handsome  octavo  volume  of  800  pages,  with 
360  illustrations.    Cloth,  $5.50  ;  leather,  $6.50 ;  lialf  Russia,  raised  bands,  $7. 

We  have  no  hesitation  in  cordially  recommend-  |  embraced  within  its  pages  is  essentially  practical, 
ing  the  translation  of  Cornil  and  Ranvier's  "  Patho-  Normal  tissues  are  di.scussed,  and  after  their  thor- 
logical  Histology"  as  the  best  worli  of  the  kind  in  |  ough  demonstration  we  are  able  to  compare  any 
any  language,  and  as  giving  to  its  readers  a  trust-  i  patliological  change  which  has  occurred  in  them, 
worthy  guiJie  in  obtaining  a  broad  and  solid  basis  Thus  side  by  side  physiological  and  pathological 
for  the  appreciation  of  the  practical  bearings  of    anatomy  go  hand  in  "hand,  affording  that  best  of 


pathological    anatomy. — Arnerican   Journal  of  the 
Medical  Sciences,  April,  1880. 

One  of  the  most  complete  volumes  on  patholog- 
ical histology  we  have  ever  seen.  The  plan  of  study 


all  processes  in  demonstrations,  comparison.  The 
admirable  arrangementof  the  work  affords  facility 
in  the  study  of  any  part  of  the  human  economy. — 
New  Orleans  Medical  and  Surgical  Journal,  June,1882. 


KIjEIN,  E.,  31.  D.,  F.  B,  S„ 

Joint  Lecturer  on  General  Anat.  and  Phys.,  in  the  Med.  School  of  St.  Bartholomeio^s  Hosp.  London. 
Elements  of  Histology.   In  one  handsome  pocket  size  12mo.  volume  of  360  pages, 
with  181  illustrations.     Limp  cloth,  red  edges,  $1.50.     Just  ready.     (See  Student^  Series  of 
Manuals,  page  5.) 

Although  an  elementary  work,  it  is  by  no  means 
superficial  or  incomplete,  for  the  author  presents 
in  concise  language  nearly  all  the  fundamental  facts 
regarding  the  microscopic  structure  of  tissues. 


The  illustrations  are  numerous  and  excellent.  We 
commend  Dr.  Klein's  Elements  most  heartily  to 
the  student. — Medical  Record,  Dec.  1, 1883. 


FEFFEB,  A,  J.,  M.  J5.,  31,  S.,  F.  It,  C,  S,, 

Surgeon  and  Lecturer  at  St.  Mary^s  Hospital,  London. 

Surgical  Pathology.     In  one  pocket-size  12mo.  volume  of  511  pages,  with  81 
illustrations.  Limp  cloth,  red  edges,  $2.00.  Ju-'^t  ready.  See  Student^  Series  of  Manuals,  page  5. 
It  is  prepared  especially  to  meet  the  requirements    illustrations  are  numerous  and  well  selected.    The 


of  the  student,  but  contains  much  of  interest  for  the 
general  practitioner.  The  author  has  succeeded 
admirably  in  putting  the  work  forward  in  the  most 
practical  form,  and  he  deserves  great  praise  for  the 
lucidity  of  style  and  brevity  of  descriptions.    The 


arrangement  is  ea.sy  and  natural.  We  would  espe- 
cially recommend  it  not  only  to  students,  but  to  all 
who  wish  a  concise  andclearexpositionof  some  of 
the  intricate  problems  of  surgical  pathology. — Nash- 
ville Journal  of  Medicine  and  Surgery,  Jan.  1884. 


GREEJS^,  T.  HENRY,  M,  D,, 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  etc. 
Pathology  and  Morbid  Anatomy.     Fifth  American  from  the  sixth  enlarged 
and  revised  English  edition.     In  one  very  handsome  octavo  volume  of  about  350  pages, 
with  about  150  fine  engravings.     In  press. 


BCHAFER'S  PRACTICAL  HISTOLOGY.  In  one 
handsome  royal  12mo.  volume  of  308  pages,  witli 
40  illustrations. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HISTOL- 


OGY. Translated  by  Joseph  Lf.idv,  M.  D.  In 
one  volume,  very  large  imperial  quarto,  with 
320  copper-plate  figures,  plain  and  colored,  and 
descriptive  letter-press.    Cloth,  S4.00. 


14       Hknbt  C.  Lka's  Son  &  Co.'s  Pdbucations — Practice  of  Med. 


Prv>/.  of  th-e  Principles  and  Prafticf  of  iled.  and  of  Clin.  Med.  m  BeUecue  Bbtpital  Medical  OMege,  N.  T. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  oi  Medicine.  "With  an  Appendix  on  the  Researches 
of  Koch,  and  their  bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of 
Phthisis.  Fifth  edition,  revised  and  largely  rewritten  In  one  large  and  closely-printed 
octavo  volume  of  1160  pages.  Cloth,  $5.50 ;  leather,  $6.50 ;  very  handsome  half  Bussia, 
raised  bands,  $7.     Just  ready. 

Koch's  discovery  of  the  bacillus  of  tubercle  gives  promise  of  being  the  greatest 
boon  ever  conferred  by  science  on  humanity,  surpassing  even  vaccination  in  its  benefits  to 
mankind.  In  the  appendix  to  his  work.  Professor  Flint  deals  with  the  subject  from  a 
practical  standpoint,  dismissing  its  bearings  on  the  etiology,  pathology,  diagnosis,  prog- 
nosis and  treatment  of  polmonary  phthisis.  Thus  enlarged  and  completed,  this  standard 
work  will  be  more  than  ever  a  necessity  to  the  physician  who  dtdy  appreciates  the  re- 
apcmsibility  of  his  calling. 


We  eaanot  eondade  this  notioe  witfaoat  expreas- 
iap  oar  admintioa  for  tlus  volame,  which  is  cer- 
tamljroaeof  tbesteiulanltext4x>okson  medicine; 
and  ve  may  eafely  affirm  that,  taken  altogether,  it 
exhUHte  a  ftaller  and  wider  aoquaintanee  with  re- 
cent pathological  inqniiy  than  anjr  similar  woiic 
with  which  we  are  aeqnalnted,  and  it  shows  its  aa- 
thor  to  be  possessed  ot  the  rare  fiMmlties  ai  clear 
exposition,  thonghtfal  diacrimination  and  soond 
jadgment. — LotHUm  Lancet,  July  23,  1881. 

In  a  word,  we  do  not  know  of  any  similar  work 
which  is  at  once  so  elaborate  and  so  eondse,  so  foil 
and  yet  so  aeeoratej  or  which  in  every  part  leaves 
apon  the  mind  the  unpressioa  of  its  being  the  pro- 
duct of  an  author  richly  stored  with  the  Craits  of 
clinical  ohserrataon,  and  an  adept  in  theart  of  con- 
veying them  dearly  and  atfameUfely  to  othera. — 
Amunca*  JamnuU  vf  Medical  Stunteet,  April,  1881- 

A  well-known  writer  and  lecturer  on  medicine 
recently  expressed  an  opinion,  in  the  highest  de- 
nee  complimentary  of  the  admirable  treatise  of 
Dr.  Flint,  and  in  enlogizing  it,  he  described  it  ac- 
corately  as  "  readable  and  reliable."  No  text-book 
is  more  calculated  to  enchain  the  interest  of  the 
student,  and  none  better  daasifies  the  multitndi- 
noos  subjects  included  in  it.    It  has  already  so  far 


I  won  its  way  in  England,  that  no  inconsiderable 
i  number  of  "men  use  it  alone  in  the  study  of  pure 
I  medicine;  and  we  can  say  of  it  that  it  is  in  every 

w^radapted  to  serve,  not  only  as  a  com  plete  guides 

but  «Uso  as  an  ample  instructor  in  the  science  ana 
j  practice  of  medicine.  The  style  of  Dr.  Flint  is 
i  always  polished  and  engaging.  '  The  work  abounds 
I  in  perspicuous  explanation,  and  is  a  most  valuable 
y  text  book  of  medicine. — Lfjtidon  M&.hra'  yewi. 
1  This  work  is  so  widely  known  and  accepted  as 
i  the  be^t  American  text-book  of  the  practice  of 

medicine  that  it  would  seem  hardly  worth  while  to 
i  give  this,  the  fifth  edition,  anything  more  than  a 
I  passing  notice.  But  even  the  most  cursory  exami- 
'  nation  shows  that  it  is,  practically,  much  more 
>  than  a  revised  edition ;  it  is,  in  fact,  rather  a  new 
I  work  throughout.  This  treatise  will  undoubtedly 
,  continue  to  hold  the  first  place  in  the  estimation 

of  American  physicians  and  students.  No  one  of 
I  our  medical  writers  approaches  Professor  Flint  in 
i  clearness  of  diction,  breadth  of  view,  and,  what  we 
I  regard  of  transcendent  importance,  rational  e^ti- 
,  mate  of  the  value  of  remedial  agents.  It  is  thor- 
i  onghly  prortiea/,  therefore  pre-eminently  the  book 

for  American  readers.— iSt.  LouU  VUti.  Bee.,  Mar.  '81. 


BASTSSOMNJE,  HHJ^fBT,  M.  J>., 

Lateig  ProfeaartfHy^tMt  tn  tk«  Umfernttf  of  Penuyivmia. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
(iX  Stod^its  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  csie 
handsnne  loyal  l^no.  volume  of  669  pages,  with  144  illustrations.  Cloth,  $2.75;  half 
bound,  $3.00. 

The  author  of  this  book  seems  to  have  spared  no  ;  papers,  etc.  We  cannot  but  admit  that  there  is  a 
pains  to  bring  it  up  to  the  modem  standpoint,  for  |  wonderful  amount  of  information  contained  in  this 
as  we  torn  over  Its  pages  we  find  many  subjects  i  woric,  and  that  it  is  one  of  the  best  of  its  kind  that 
introduced  which  have  only  lately  been  brob^t  j  we  have  seen. — Glasgow  Medical  Journal,  Nov.  1882. 
before  the  profession.    Certainly  ammigst  hooka  of  j     An  indispensable  book.    No  work  ever  exhibited 


its  class  it  deserves  and  bas  obtained  a  good  posi- 
tion. On  the  whole  it  is  a  carefol  and  conscien- 
tions  piece  of  work,  and  may  be  eommended. — 
Lomdam  Lancet,  June  31^,  1882. 

Within  Ote  eompaas  of  600  pages  it  treats  <rftbe  I 
history  of  medicme,  general  pathology;  general 


symptomatology.and  physical  diagnosis (bidnding  i  tials,  as  the  name  suggests,  are  not  intended  to 
laiyngoeot^te,  ophthalmoseape,  etc.).  general  ther-  •  supersede  the  text-books  of  Flint  and  Bartholow, 
Mieati^naaotogy,  and  special  pathMogy  and  prac- 1  but  they  are  the  most  valuable  in  affording  the 
noe.  With  such  a  wide  range,  condoisation  is,  of  i  means  to  see  at  a  glance  the  whole  literature  of  any 
ooane,a  neoeasity;  but  the  author  has  endeavored  I  disease,  and  the  most  valuabletreatment. — Ckieago 
to  make  up  Cw  this  by  copious  rriierenoes  to  original  I  MediaU  Jommal  and  Examiiter,  April,  1882. 


a  better  average  of  actual  practical  treatment  than 
this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshome  for 
omdensing  all  the  views  of  eminent  practitioners 
Into  a  12mo.  The  namerons  illustrations  will  be 
very  usefol  to  students  especially.    These  essen- 


BniSTOWE,  JOJEOS^  STJER,  M.  X>.,  F,  M.  C.  T., 

Physidan  and  Joint  Lttturer  on  Medicine  at  SL  Thoma^  HotpitaL 

A  Treatise  on  the  Practice  of  Medicine.  Second  American  edition,  revised 
by  Uie  Author.  Edited,  with  addititms,  by  James  H.  Hctpchtssox,  M.D.,  physician  to  the 
Pennsylvania  HoepitaL  In  one  handsome  octavo  volume  of  lOS-S  pages,  with  illustrations. 
Cl0di,*$5.OO;  leather,  $6.00;  voy  handsome  half  Russia,  raised  beuids,  $6.50. 

author  in  following  the  latest  growth  of  medical 
science. — BotUmMediealaiid  Surgical  Journal,  Feb. 
1880L 


The  second  edition  of  this  excellent  work,  like 
the  first,  has  received  the  benefit  of  Dr.  Hotehin- 
■on's  annotationa,  hy  which  the  phases  of  disease 
which  are  peculiar  to  this  connliy  are  indicated, 
and  thus  a  treatise  which  was  Intended  for  British 
praetitiMiers  and  students  is  made  m<He  practieally 
ns^tal  on  this  side  <^  the  water.    We  see  no  reason 


to  modify  the  bi^  <^inion  previously  expressed 
wHh  re^ird  to  Dr.  Bnstowe's  work,except  oy  add- 


The  reader  will  find  every  conceivable  subject 
connected  with  the  practice  of  medicine  ably  pre- 
sented, in  a  style  at  once  clear,  interesting  and 
concise.  The  additions  made  by  Dr.  Hu  tchinson 
are  appropriate  and  practical,  and  great^  add  to 
_  .         ,      ,  its  nsefolness  to  American  readers. — Buffalo  Mtdr- 

lug  our  appieeiataon  of  the  carefol  labors  of  the  '  ieal  and  Sargieal  Jommal,  March,  1880. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ^Practice  of  Med.       15 
METJS^OLJDS,  jr.  RUSSELL,  M,  2>., 

Profamr  of  the  Principles  and  Practice  of  Medicine  in  University  QMege,  Xondem. 

A  System  of  Medicine.    With  notes  and  additions  by  Hexky  Habtshorite, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.     In  three  large 
and  handsome  octavo  volumes,  containing  30-56  double-columned  pages,  with  317  illostn- 
tions.    Price  per  volume,  cloth,  $5.00 ;  sheep,  $6.00 ;  very  handsome  half  Bossia,  raised  bands, 
$6.50.     Per  set,  cloth,  $15 ;  sheep,  $18 ;  half  Kussia,  $19.50.    Sold  only  by  gubgcription. 
Volume  I.    Contains  General  Diseases  and  Diseases  of  the  Nervous  System. 
Volume  II.    Contains  Diseases  of  RESPmATORY  and  Circuiatory  &s^tems. 
Volume  III.    Contains  Diseases  of  the  Digestite,  BLOOi>-GLA>tDULAR,  URDf  aby,  Rb- 
PBODUCTTVE  and  CuTAJfEous  Systems. 
Reynolds'  System  of  Medicike,  recently  completed,  has  acquired,  since  the  first  ap- 
pearance of  the  first  volume,  the  well-deserved  reputation  of  being  the  work  in  which 
modem  British  medicine  is  presented  in  its  fullest  and  most  practical  form.    This  could  . 
scarce  be  otherwise  in  view  of  the  fact  that  it  is  the  result  of  the  collaboration  of  the  lead- 
ing minds  of  the  profession,  each  subject  being  treated  by  some  gentleman  who  is  r^arded 
as  its  highest  authority.     All  the  leading  schools  in  Great  Britain  have  contiibated  their 
best  men,  in  generous  rivalry,  to  build  up  this  monument  of  medical  science.    That  a  wcm^ 
conceivetl  in  such  a  spirit  and  carried  out  under  such   auspices  should  prove  an  indis- 
pensable treasury  of  facts  and  experience,  suited  to  the  daily  wants  of  the  practitioner,  was- 
inevitable ;  and  the  success  which  it  has  enjoyed  in  England,  and  the  reputation  which 
it  has  acquired  on  this  side  of  the  Atlantic,  have  sealed  it  with  the  approbation  of  the 
two  pre-eminently  practical  nations. 

Its  large  size  and  high  price  having  kept  it  beyond  the  reach  of  many  practitioners  in 
this  country  who  desire  to  possess  it,  a  demand  has  arisen  for  an  edition  at  a  price  which 
shall  render  it  accessible  to  all.  To  meet  this  demand  the  present  edition  has  been  under- 
taken. The  five  volumes  and  five  thousand  pages  of  the  original  have,  by  the  use  of  a 
smaller  type  and  double  colimans,  been  compressed  into  three  volumes  of  over  three 
thousand  pages,  clearly  and  handsomely  printed,  and  ofiered  at  a  price  which  renders  it 
one  of  the  cheapest  works  ever  presented  to  the  American  profession. 

But  not  only  is  the  American  edition  more  convenient  and  lower  priced  than  the  Eng- 
lish ;  it  is  also  better  and  more  complete.  Some  years  having  elapsed  since  the  appearance 
of  a  portion  of  the  work,  additions  were  required  to  bring  up  the  subjects  to  the  existing  con- 
dition of  science.  Some  diseases,  also,  which  are  comparatively  unimportant  in  England, 
require  more  elaborate  treatment  to  adapt  the  articles  devoted  to  them  to  the  wants  of  the 
American  physician ;  and  there  are  points  on  which  the  received  practice  in  this  country 
difi'ers  from  that  adopted  abroad.  The  supplying  of  these  deficiencies  has  been  undertaken 
by  Henry  Hartshorne,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsyl- 
vania, who  has  endeavored  to  render  the  work  fiilly  up  to  the  day,  and  as  useful  to  the 
American  physician  as  it  has  proved  to  be  to  his  English  brethren.  The  number  of  illiis- 
trations  has  also  been  largely  increased,  and  no  eflSjrt  spared  to  render  the  typographical 
execution  unexceptionable  in  every  respect. 

8o  concise  and  thoroa^  and  withal  so  Ineid  and 
trustworthy.  In  that  tvandKrf'mediciiie  in  which 
th«  rank  and  file  of  the  profession  are  mainly  in- 
terested;  viz.,  the  pnctieal  part,  thenqpeotiea^  Rey- 
nolds, without  intendme  anr  invidioos  eomnariaoa, 
stands  pre-eminent,  l^e  theiapenties  of  the  Bn^ 
lisb  correspond  mwe  eloaely  than  thoaa  of  any 
other  coantTT  with  those  of  this  eoantiy,  and  Om 
American  editor  of  Bejmcrids'  has  broa^it  fliia 
branch  op  to  the  most  advanced  Amenean  stand- 
ard.—JftdM^oa  Medina  Nm*,  Feb.  15, 1880. 

These  three  vohimes  are  a  whole  libnur  in  and 
of  themselves.  As  works  of  reference  they  are 
destined  to  be  for  many  years  r^arded  as  tha 


There  is  no  medical  work  which  we  have  in 
times  past  more  frequently  and  fully  consulted 
when  perplexed  by  doubts  as  to  treatrnent,  or  by 
having  unusual  or  apparently  inexplicable  symp- 
toms presented  to  us,  than  "Reynolds'  System  of 
Medicine."  It  contains  just  that  kind  of  informa- 
tion which  the  busy  practitioner  frequently  finds 
himself  in  need  of.'  In  order  that  any  deficiencies 
may  be  supplied,  the  publishers  have  committed 
the"  preparation  of  the  book  for  the  press  to  Dr. 
Henry  Hartshome,  whose  judicious  notes  distrib- 
uted throughout  the  volume  aiford  abundant  evi- 
dence of  the  thoroughness  of  the  revision  to  which 

he  has  subjected  it. — American  Journal  of  the  Med-     __    __ ^  ^ ^_^ 

teal  Hcienees,  Jan.  IS^X  i  yery  highest  authority  on  medic^  subjects. 

Certainly  no  work  with  which  we  are  acquainted  guage  is  scarcely  adequate  to  express  the  actoal 
has  ever  been  given  to  the  English-reading  profes-  value  to  general  practitioners  of  such  a  nviein  of 
sion  which  treats  of  so  many  diseases  in  a  manner     medicine  as  this. — Omammati  Lmmeet  cad  Cttnc 

WATSOX,  THOMAS,  M,  X)., 

Late  Phijsieian  in  Ordinanj  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  Delivered  at  King's 
College,  London.  A  new  American  from  the  fifth  English  edition,  revised  and  enlarged. 
Edited,  with  additions,  and  190  illustrations,  by  Henry  Hartshorne,  A.  M.,  M.  D.,  late 
Professor  of  Hvgiene  in  the  Universitv  of  Pennsvlvania.  In  two  large  and  handsome octeTO 
volumes,  containing  1840  pages.     Clo'th,  $9.00  ;'  leather,  $11.00. 

WOODBUBT,  FBAJSIK,  M,  !>., 

Phi/iieian  to  the  German  Hospital,  Philadelphia  ;  late  CkMfAssuUaU  to  the  Medieal  CSateta  Jef«r- 

ion  College  Hospital,  etc. 

A  Handbook  of  the  Principles  and  Practice  of  Medicine.  Ftar  the  use 
<rf  Students  and  Practitioners.   In  one  royal  12mo.  volume,  with  illustrations.  Prepcerimg. 

A   CENTUKY  OF  A3IERICAN  MEDICDfE,  177e— 1876,     By  Drs.  E.  H.  Claskz,  H.  J. 

Bkklow,  S.  D.  Geos«:,  T.  G.  Tbomas,  and  J.  S.  BiuostH;.    In  one  12mo.  volome  of  370pages.    C3o«h,S2;Jfi. 


16      Henry  C.  Lea's  Son  &  Co.'s  Publications — Clinical  Med.,  etc. 


FOTHBBGILL,  J.  M.,  M.  !>.,  JEdin.,  M,  B,  C,  J».,  Zond., 

Asst.  Pht/s.  to  the  West  Lond.  Hoxp.,  Asst.  Phys.  to  the  City  of  Lond.  Hosp.,  etc. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics. Second  edition,  revised  and  enlarged.  In  one  very  handsome  octavo  volume  of  651 
pages.     Cloth,  $4.00 ;  very  handsome  half  Russia,  raised  bands,  $5.50. 


A  book  which  can  give  correctly  and  interest- 
ingly, as  well  as  scientifically,  the  method  of 
prescribing  and  the  rationale  of  the  best  thera- 
peutics in  the  treatment  of  disease,  is  manifestly 
just  the  work  which  each  physician  desires.  It  is 
not  extravagant  eulogy  to  say  that  the  physician 
will  find  in  this  work  of  Fothergill  the  guide  which 
he  seeks  for  his  therapeutics;  for  not  only  is  the 
treatment  which  he  seeljs  already  indicated  herein, 
but  the  rationale  of  the  treatment  is  as  clearly  ex- 
plained.— GaiUard's  Med.  Journ.,  Sept.  1880. 

The  author  merits  the  thanks  of  every  well-edu- 


impress  of  a  master-hand;  and  while  the  work  is 
thoroughly  scientific  in  every  particular,  it  presents 
to  the  tnoiightful  reader  all  the  charms  and  beau- 
ties of  a  well-written  novel.  No  physician  can 
well  afford  to  be  without  this  valuble  work,  for  its 
originality  makes  it  fill  a  niche  in  medical  litera- 
ture hitherto  vacant. — Nashville  Juurn.  of  Med.  and 
Surg.,  Oct.  1880. 

The  junior  members  of  the  profession  will  find 
it  a  work  that  should  not  only  be  read  but  care- 
fully studied.  It  will  assist  them  in  the  proper 
selection  and  combination  of  therapeutical  agents 


cated  physician  for  his  efforts  toward  rationalizing  j  best  adapted  to  each  case  and  condition,  and 
the  treatment  of  diseases  upon  the  scientific  basis  I  enable  them  to  prescribe  intelligently  and  success- 
of  physiology.    Every  chapter,  every  line,  has  the  j  fully. — St.  Louis  Courier  of  Medicine,  Nov.  1880. 


FLIIST,  AUSTIW,  31,  D. 

Clinical  Medicine.  A  Systematic  Treatise  on  the  Diagnosis  and  Treatment  of 
Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In  one  large  and  Iiand- 
some   octavo  volume   of  799  pages.     Cloth,  $4.50 ;  leather,  $5.50 ;  half  Russia,  $6.00. 

of  advanced  medicine  in  this  country  as  that  ot 
the  autlior  of  two  works  of  great  merit  on  special 
subjects,  and  of  numerous  papers  exhibiting  much 
originality  and  extensive  research. — The  Dublin 
Journal,  Dec.  1879. 
The  great  object  is  to  place  before  the  reader 


It  is  here  that  the  skill  and  learning  of  the  great 
clinician  are  displayed.  He  has  given  us  a  store- 
house of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  practitioner,  the  result  of 
a  long  life  of  the  most  faithful  clinical  work,  col- 
lected by  an  energy  as  vigilant  and  .systematic  as 
untiring,  and  weighed  by  a  judgment  no  less  clear 
than  his  observation  is  close. — Archives  of  Medicine, 
Dec.  1879. 

To  give  an  adequate  and  useful  conspectus  of  the 
extensive  field  of  modern  clinical  medicine  is  a  task 
of  no  ordinary  difficulty;  but  to  accomplish  this  con- 
sistently witn  brevity  and  clearness,  the  different 
subjects  and  their  several  parts  receiving  the 
attention  which,  relatively  to  their  importance, 
medical  opinion  claims  for  them,  is  still  more  diffi- 
cult. This  task,  we  feel  bound  to  say,  has  been 
executed  with  more  than  partial  success  by  Dr. 
Flint,  whose  name  is  already  familiar  to  students 


the  latest  observations  and  experience  in  diagnosis 
and  treatment.  Such  a  work  is  especially  valuable 
to  students.  It  is  complete  in  its  special  design, 
and  yet  so  condensed  that  they  can  by  its  aid  keep 
up  with  the  lectures  on  practice  without  neglect- 
ing other  branches.  It  will  not  escape  the  notice 
of  the  practitioner  that  such  a  work  is  most  valu- 
able in  culling  points  in  diagnosis  and  treatment 
in  the  intervals  between  the  daily  rounds  of  visits, 
since  he  can  in  a  few  minutes  refresh  his  memory 
or  learn  the  latest  advance  in  the  treatment  of 
diseases  which  demand  his  instant  attention. — 
Cincinnati  Lancet  and  Clinic,  Oct.  25,  1879. 


By  the  Same  Author. 

Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

FINLAYSOJSr,  JA3IES,  M,  D.,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Olasgow  Western  Infirmary,  etc. 
Clinical  Diagnosis.  A  Handbook  for  Students  and  Practitioners  of  Medicine. 
With  Chapters  by  Prof.  Gairdner  on  the  Physiognomy  of  Disease ;  Prof.  Stepliens  on 
Diseases  of  the  Female  Organs;  Dr.  Robertson  on  Insanity;  Dr.  Gemmell  on  Physical 
Diagnosis ;  Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor 
on  Case-taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  In 
one  handsome  12mo.  volume  of  546  pages,  with  85  illustrations.     Cloth,  $2.63. 


This  is  one  of  the  really  useful  books.  It  is  at- 
tractive from  preface  to  the  final  page,  and  ought 
to  be  given  a  place  on  every  office  table,  because  it 
contams  in  a  condensed  form  all  that  is  vahiable 
in  semeiology  and   diagnostics   to  be  found   in 


bulkier  volumes;  and  because  of  its  arrangement 
and  complete  index  it  is  unusually  convenient  for 
quick  reference  in  any  emergency  that  may  come 
upon  the  busy  practitioner. — N.  C.  Med.  Journ., 
Jan.  1879. 


FENWICK,  SAMUEL,  M,  !>,, 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 


TAJiWEB,  THOMAS  HAWKES,  M.  D. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Revised  and  enlarged  by  Tilbury  Fox,  M.  D.,  Phy- 
sician to  the  Skin  Department  in  University  College  Hospital,  London,  etc.  In  one  small 
12mo.  volume  of  362  pages,  with  illustrations.     Cloth,  $1.50. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
12mo.  volume  of  127  pages.    Cloth,  81.25. 

DAVIS'  CLINICAL    LECTURES    ON  VARIOUS 


IMPORTANT  DISEASES;  being  a  collection  ot 
the  Clinical  Lectures  delivered  in  the  Medical 
Ward  of  Mercy  Hospital,  Chicago.  Edited  by 
Frank  H.  Davis,  M.  D.  Second  edition.  In  one 
royal  12mo.  volume  of  287  pages.    Cloth,  $1.76. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Electric,  Prac,  etc.     17 


RICHARDSON,  B.  TT.,  M.A,,  M.jy,,  LL.  D,,  F,R.S.,  F,S,A, 

Fellow  of  the  Royal  College  of  Physicians,  London. 
Preventive  Medicine.     In  one  octavo  volume  of  729  pages.    Cloth,  $4;  leather, 
$5  ;  very  handsome  half  Russia,  raised  bands,  $5.50.    Just  ready. 


Though  this  work  has  been  written  with  spe- 
cial reference  to  non-professional  readers,  it  excels 
any  other  book  which  has  before  fallen  under  our 
observation  on  the  subject  of  which  it  treats,  as  a 
text-book  for  the  medical  reader.  It  comprehends 
the  nature,  causes  and  prevention  of  disease  from 
a  .strictly  scientific  standpoint.  The  American 
publishers  have  done  the  medical  profession  a 
valuable  service  in  laying  it  before  them  as  a 
work  that  contains  much  with  which  every  phy- 
sician should  be  ftimiliar.  There  is  no  other  work 
In  the  language  in  which  the  information  here 


presented  can  be  found  so  systematically  arranged 
and  intelligently  presented. — The  Sanitarian, 
March,  1884. 

This  is  a  book  that  will  surely  find  a  place  on  the 
table  of  every  progressive  physician.  To  the 
medical  profession,  whose  duty  isquite  as  much  to 
prevent  as  to  cure  disease,  thebook  will  be  a  boon. 
— Boston  Medical  and  Surr/ical  Journa!,  Mar.  C,  1884. 

The  treatise  containsavastamount  of  solid,  valu- 
able hygienic  information. — Medical  and  Surgical 
Reporter,  Feb.  23, 1884. 


Excerpt  from  Contents. 
I. — Disease  as  a  Unity,  with  a  variety  of  Phenomena.  The  Preventive  Scheme  of 
Medicine.  General  Diseases  of  ISlankind.  1.  Constitutional  Diseases.  2.  Local  Diseases. 
3.  Diseases  from  Natural  Accidents, — Lightning — Sunstroke — Starvation — Poisons — 
Venoms — Poisonous  Food — Pregnancy.  11.  Acquired  Diseases  of  Artificial  Origin  ; 
Phenomena  and  Course.  1.  Acquired  Diseases  from  Inorganic  and  Organic  Poisons, — 
Tea — Coffee — Alcoliol — Tobacco — Soot — Gases.  2.  Acquired  Diseases  from  Physical 
Agencies,  Mechanical  and  General, — Dusts — Pressure  on  Lungs — Concussions  and  Shocks 
— Muscular  Overwork  and  Strain — Acquired  Deformities — Physical  Injuries — Surgical 
Operations.  3.  Acquired  Diseases  from  Mental  Agencies, — Moral,  Emotional  and 
Habitual.  Diseases  from  Mental  Shock,  from  Moral  Contagion, — Tarantisni — Suicide, 
from  Hysterical  Emotion,  from  Passion,  from  Habits  of  Life — Insomnia — Dementia — 
Slotli — Luxury — Secret  Immorality.  III. — 1.  Origins  and  Causes  of  Disease, — Congenital, 
Hereditary  or  Constitutional  Causes  ;  Atmospheric  and  Climatic  Causes ;  Parasitic  Causes, 
— Bacteria — Bacilli — Spirilla — Trichinae;  Zymotic  Causes;  Industrial  and  Accidental 
Causes;  Social  and  Psychical  Causes;  Senile  Degenerative  Causes.  2.  Preventions  of 
Disease.  Prevention  of  Hereditary  or  Constitutional  Diseases, — Personal  Rules  for  Preg- 
nancy, Infancy,  Adolescence,  Maturity ;  Prevention  of  Atmospheric  and  Climatic  Diseases; 
of  Parasitic  Diseases, — Pereonal  Rules ;  of  Zymotic  Diseases, — Contagion — Drainage — 
Isolation  of  Sick — Water  and  Milk  Supply — Hospitals — Registration — Vaccination — 
Other  Inoculations — Legislation ;  Prevention  of  Industrial  Diseases — Lead  Poisoning — 
Dusts — Gases,  etc. ;  Prevention  of  Social  and  Psychical  Diseases, — Warming  and  Ventila- 
tion— Light — Water — the  Bed-room — Bread — Abattoirs — Schools — Sepulturer-Drunken- 
ness ;  Prevention  of  Senile  Disease. 


BARTHOLOW,  ROBERTS,  A,  M.,  M.  !>.,  LL.  J)., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Phi  la.,  etc. 

A  Practical  Treatise  on  the  Applications  of  Electricity  to  Medicine 

and  Surgery,     Second  edition.     In  one  very  handsome  octavo  volume  of  292  pages,  with 
109  illustrations.     Cloth,  §2.50. 

The  second  edition  of  this  work  following  so  I  A  most  excellent  work,  addressed  by  a  practi- 
8oon  upon  the  first  would  in  itself  appear  to  be  a  tioner  to  his  fellow-practitioners,  and  therefore 
sufficient  announcement;  nevertheless,  the  text  !  thoroughly  practical.  The  work  now  before  ua 
has  been  so  considerably  revised  and  condensed,  i  has  the  exceptional  merit  of  clearly  pointing  out 
and  so  much  enlarged  by  the  addition  of  new  mat-  !  wliere  the  benefits  to  be  derived  from  electricity 


ter,  that  we  cannot  fail  to  recognize  a  vast  improve- 
ment upon  the  former  work.  The  author  lias  pre- 
pared his  work  for  students  and  practitioners — for 
those  who  have  never  acquainted  themselves  with 
the  subject,  or,  having  done  so,  find  that  after  a 
time  their  knowledge  needs  refreshing.  We  think 
he  has  accomplished  this  object.  The  book  is  not 
too  voluminous,  but  is  thoroughly  practical,  sim- 
ple, complete  and  comprehensible.  It  is,  more- 
over, replete  with  numerous  illustrations  of  instru- 
ments, appliances,  etc. — Medical  Record,  November 
15, 1882. 


must  come.  It  contains  all  and  everytliing  that 
the  practitioner  needs  in  order  to  understand  in- 
telligently the  nature  and  laws  of  the  ajjent  he  is 
making  use  of,  and  for  its  proper  application  in 
practice.  In  a  condensed,  practical  form,  it  pre- 
sents to  the  physician  all  that  he  would  wish  to 
rememberafterperusingawhole  library  on  medical 
electricity,  including  the  results  of  the  latest  in- 
vestigations. It  is  the  boolv  for  the  practitioner, 
and  tlie  necessity  for  a  second  edition  proves  thai 
it  has  been  appreciated  by  the  profession. — Physi- 
cian and  Surgeon,  Dec.  1882. 


HABBRSHOW,  S,  O.,  Jf.  !>., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Chty^s  Hospital,  Loiidon. 
On  the  Diseases  of  the  Abdomen ;     Comprising  those  of  tlie  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  Oesophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.     In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  $3.50. 


PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.    Cloth,  82.00. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  .SICKNESS.  In  one  hand- 
some octavo  volume  of  302  pp.    Cloth,  $2.75. 


BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Condib, 
M.D.    1  vol.  8vo.,  pp.  603.     Cloth,  82.50. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.    Cloth,  82.50. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLBO- 
TIONS.    1  vol.  8vo.,  pp.  493.    Cloth,  $3.50. 


18       Henry  C  Lea's  Son  &  Co.'s  Publications — Throat,  Lungs,  etc. 


SBILBJR,  CAUL,  M,  !>., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  Second  edition.  In  one  handsome  royal  12mo.  volume 
of  294  pages,  with  77  illustrations.     Cloth,  $1.75.     Jtist  ready. 


Dr.  Seller's  book  is  a  clear,  concise,  practical 
exposition  of  the  subject,  such  as  only  a  master  of 
it  could  have  written.  It  is  better  suited  to  the 
wants  of  advanced  students  and  voung  physicians 
than  any  other  at  present  in  the  hands  of  "the  pro- 
fession.— American  Practitioner,  Aug,  1883. 


Dr.  Seller's  treatise  contains  all  the  essentials  of 
the  knowledge  of  the  important  localities  com- 
pressed into  a  small  space  and  put  together  by 
one  of  the  ablest  of  American  specialists.  To  stu- 
dents and  otiiers  this  book  can  he  recommended 
as  one  of  the  best  and  most  generally  useful. — 
Canada  Medical  and  Surgical  Journal,  July,  1883. 


BMOWNE,  LENNOX,  F.  M.  C,  S,,  Bdin,, 

Senior  Surgeon  to  the  Central  London  Throat  and  Ear  Hospital,  etc. 
The  Throat  and  its  Diseases.     Second  American  from  the  second  English  edi- 
tion, thoroughly  revised.     With  100  typical  illustrations  in  colors  and  50  wood  engravings, 
designed  and  executed  by  the  Author.     In  one  very  handsome  imperial  octavo  volume  of 
about  350  pages.     Preparing. 

FLINT,  AUSTIN,  M.  B., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Third  edition.  In  one  hand- 
some royal  12mo.  volume  of  240  pages.     Cloth,  $1.63.     Just  ready. 


This  practical  and  justly  popular  manual  is  con- 
Tenientl^  divided  into  eight  chapters,  and  the 
student  is  gradually  led  up  from  a  general  con- 
sideration of  physical  signs  in  health  and  disease 
to  the  differential  diagnosis  of  diseased  conditions 
by  a  knowledge  of  these  physical  signs.  As  in  his 
courses  of  practical  instruction,  so  in  this  book 
the  author's  plan  is  to  simplify  the  subject  as 
much  as  possiole ;  to  consider  the  distinguishing 
characteristics  of  different  physical  signs  as  de- 


termined by  analysis,  and  as  based  particularly  on 
the  variations  in  the  intensity,  pitch  and  quality 
of  sounds;  to  impress  the  facts  upon  the  student 
and  reader  that  the  significance  of  physical  signs 
relates  to  certain  physical  conditions,  and  tnat 
close  study  of  the  physical  conditions  in  health 
and  disease  is  a  sine  qua  non  of  success  in  both 
diagnosis  and  treatment. — The  Medical  News, 
April  28,  1883. 


By  the  Same  Author. 
Physical  Exploration  of  the  Lungs  by  Means  of  Auscultation  and 
Percussion.     Three  lectures  delivered  before  the  Philadelphia  County  Medical  Society, 
1882-83.     In  one  handsome  small  12mo.  volume  of  83  pages.     Cloth,  $1.00. 

By  the  Same  Author. 
A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.    Second  and 
revised  edition.     In  one  handsome  octavo  volume  of  591  pages.     Cloth,  $4.50. 

By  the  Same  Author. 
Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.     In  one  handsome  octavo  volume  of  442  pages. 

Cloth,  $3.50. 

By  the  Same  Author. 
A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.     Second  revised  and  enlarged  edition.     In  one  octavo  volume 
of  550  pages,  with  a  plate.     Cloth,  $4. 

GBOSS,  S.  B.,  M.B.,  LL.B,,  B.CL,  Oxon.,  LL.B.  Cantab, 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.    In  one 

octavo  volume  of  452  pages,  with  59  illustrations.     Cloth,  $2.75. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  83.50. 

8LADEON  DIPHTHERIA;  its  Nature  and  Treats 
ment,  with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  pp.  158.    Cloth,  $1.25. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  82.50. 

SMITH  ON  CONSUMPTION;  its  Earlv  and  Reme- 
diable Stages.     1  vol.  8vo.,  pp.  253.    82.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  $3.00. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.    In  1  vol.  8vo.,  416  pp.     Cloth,  $3.00. 


STOKES'  LECTURES  ON  FEVER.  Edited  by 
John  William  Moore,  M.  D.,  F.  K.  Q.  C.  P.  In 
one  octavo  volume  of  280  pages.    Cloth,  $2.00. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.    In  one  8vo.  vol.  of  354  pp.    Cloth,  $2.25. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.   In  one  8vo.  vol.  of  303  pp.  Cloth,  ^50. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.    Cloth,  $7.00. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS,  by  C.  Hanbfiei.d  Jonbs, 
M.  D.  Second  American  edition.  In  one  hand- 
some octavo  volume  of  340  pages.     Cloth,  $3.86'. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,etc.  ID 
SAMIZTOJV^,  ALLAJS^  McLAJSTE,  M,  D., 

Attending  Physician  at  the  Hospital  for  Epilevties  and  Paralytics,  BlackweWs  Island,  N.  Y.,  and  at 
the  Out-Patients'  Department  of  the  New  York  Hospital. 

Nervous  Diseases ;  Their  Description  and  Treatment.     Second  edition,  thoroughly 
revised  and  rewritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 


We  are  glad  to  welcome  a  second  editiou  of  so  use- 
ful a  work  as  this,  in  which  Dr.  Hamilton  has  suc- 
ceeded in  condensing  into  convenient  limits  the 
most  important  of  the  recent  developments  in  re- 
gard to  diseases  of  the  nervous  system.  Of  recent 
years  nervous  pathology  has  attained  to  such  im- 
portance as  to  necessitate  very  careful  description 
in  special  works,  and  among  these  this  volume 
must  take  a  liigh  place.  This  volume  is  on  the  whole 
excellent,  and  is  devoid  of  that  spirit  of  plagiarism 
which  we  have  unfortunately  seen  too  much  of  in 
certain  recent  English  works  on  nervous  diseases. 
— Edinburgh  Medical  Journal,  May,  1882. 


When  thefirstedition  of  this  good  book  appeared 
we  gave  it  our  emphatic   endorsement,  and  the 

C resent  edition  enhances  our  appreciation  of  the 
ook  and  its  author  as  a  safe  guide  to  students  of 
clinical  neui'ology.  One  of  the  best  and  moat 
critical  of  English  neurological  journals,  Brain,  has 
characterized  this  book  as  the  best  of  its  kind  in 
any  language,  which  is  a  handsome  endorsement 
from  an  exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  posse.ss  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TUKE,  DAWIEL  HACK,  31,  2>., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thorouglily  revised  and  rewritten.  In  one  handsome  octavo  volume  of  467  pages,  with 
two  colored  plates.     Cloth,  $3.00.     Just  ready. 

The  immense  power  of  the  imagination,  both  in  causing  and  curing  disease,  has  been 
recognized  from  the  infancy  of  medical  science,  but  the  practical  application  of  this  fact 
has  hitherto  been  cliiefly  confined  to  charlatans  and  has  always  been  one  of  the  secrets  of 
their  frequent  success.  To  rescue  this  invaluable  therapeutic  agent  fi-om  unmerited  ill- 
repute,  and  to  obtain  its  recognition  as  a  legitimate  instrument  of  the  regular  profession, 
is  briefly  the  object  of  this  volume.  Not  only  is  tlie  work  thus  one  of  high  importance 
to  the  practitioner  wlio  desires  to  utilize  all  the  resources  of  his  art,  but  in  its  authentic 
revelations  of  the  fantastic  interaction  of  man's  dual  nature,  it  rivals  in  some  of  its  narratives 
the  most  interesting  creations  of  fiction.  The  favor  with  which  the  work  has  hitherto 
been  received  will  be  enlianced  by  the  labor  bestowed  in  the  revision  as  well  as  by  the 
addition  of  two  carefully  prepared  colored  plates. 


CLOUSTON,  THOMAS  S,,  M,  JD.,  F,  M.  C,  P.,  L,  B.  C,  S,, 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Exhaustive  Summary  of  the  Laws  in  Force  in  the  United  States  upon  the  Commit- 
ment and  Confinement  of  the  Insane.  By  Chaeles  F.  Folsom,  M.  D.,  Assistant  Pro- 
fessor of  Mental  Diseases,  Medical  Department  of  Harvard  University.  In  one  hand- 
some octavo  volume  of  about  600  pages,  illustrated  with  woodcuts  and  eight  lithographic 
plates,  four  of  which  are  beautifully  colored.     Cloth,  $4.     In  a  few  days. 

At  the  author's  request.  Professor  P^olsom  luis  critically  examined  this  work,  and  haa 
specially  prepared  for  it  the  appendix  on  United  States  laws  relating  to  the  insane.  The 
work  will  thus  afford  American  practitioners  a  complete  and  trustworthy  guide  in  medical 
and  legal  questions  arising  from  cases  of  mental  disease. 


We  should  say  that  to  have  read  a  book  like  Dr. 
Clouston's  lectures,  and  mastered  his  definitions, 
must  make  a  man  as  well  prepared  as  books  can 
make  him,  to  recognize  the  principal  symptoms 
of  insanity.  We  feel  that  every  statement  has 
been  weighed,  considered  and  viewed  In  many 
different  relations.  The  student  gets  all  the  in- 
formation about  the  symptoms  and  treatment  of 
insanity  in  well    considered  words.    It  maj'  be 


viewed  as  a  proof  of  the  thoroughness  of  the  work 
and  the  originality  of  the  author,  that  so  much  care 
lias  been  taken  with  the  therapeutics  of  insanity. 
Dr.  Clouston  has  sought  out  and  thought  out,  by 
observation  and  expermient,  methods  of  treatment 
suitable  to  the  various  forms  of  insanity,  which 
constitute,  perhaps,  the  most  valuable  features  of 
the  book. — Edinburgh  Medical  Journal,  Feb.  1884. 


PLAYFAIM,  W.  S.,  M.  J>.,  F.  B,  C,  F. 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 

one  handsome  small  12mo.  volume  of  97  pages.     Clotli,  $1.00.     Just  ready. 


The  book  is  well  worth  perusal,  and  will  repay 
anyone  for  the  time  spent  in  its  careful  study,  in- 
asmuch as  it  will  lead  to  a  better  understanding  of 
the  management  of  those  bites  noirs  of  the  physi- 
cian, nerve  prostration  and  hysteria.  Details  are 
given  of  the  manner  of  carrying  out  the  treatment. 


to  which  are  added  the  histories  of  a  number  of 
cases  illustrative  of  the  method  and  its  results. 
An  appendix  contains  a  description  of  the  method 
of  performing  massage,  which  is  clear  and  con- 
cise.— Neiv  Orleans  Medical  and  Surgical  JowneU, 
May,  1883. 


MITCHELL,  S,  WEIB,  M,  !>., 

Physician  to  Orthopaedic  Hospital  and  the  Infirmai-y  for  Diseases  of  the  Nervous  System,  Phila.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  \yomen. 
Second  edition.     In  one  very  handsome  12mo.  volume  of  about  250  pages.     Preparing. 

*'  Blandford  on  Insanity  and  its  Treatment:  Lectures  on  the  Treatment, 
Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane,  by  Isaac  Ray,  M.  D.  In  one  T«y 
handsome  octavo  volume. 


20 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Surgery^ 


GBOSS,  S.  Z>.,  31.  n.y  LL,  2).,  I).  C,  L.   Oxon,,  ii.  D, 

Cctntab.f 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery :    Pathological,    Diagnostic,  Therapeutic  and   Operative. 
Sixth  edition,  tlioronghly  revised  and  greatly  improved.     In  two  large  and  beautifully- 
printed  imperial  octavo' volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  §15 ;  half  Eussia,  raised  bands,  $16. 
The  work  as  a  whole  needs  no  commendation.  I  fully  maintains  the  reputation  the  work  has  ac- 


Many  years  ago  it  earnedfor  itself  the  enviable  rep- 
utation of  tlie  leading  American  work  on  surgery, 
and  it  is  still  capable  of  maintaining  that  standard. 
The  reason  for  this  need  only  be  mentioned  to  be 
appreciated.  The  author  has  alwavs  been  calm 
and  Judicious  in  liis  statements,  has  based  his  con- 
clusions on  much  study  and  personal  experience, 


quired.  It  has  become  a  complete  and  systematic 
book  of  reference  alike  for  the  student  and  the 
practitioner. — The  London  Lancet,  Jan.  27, 1883. 

We  regard  Gross'  System  of  Surgery  not  only  as 
a  singularly  rich  storehouse  of  scientific  informa- 
tion, but  as  marking  an  epoch  in  the  literary  his- 
toiy  of  surgery.    The  present  edition  has  received 


has  been  able  to  grasp  his  subject  in  its  entirety,  j  the  most  careful  revision  at  the  hands  of  the  emi- 
and,  above  all,  nas  conscientiously  adhered  to  i  nent  author  himself,  assisted  in  various  instances 
truth  and  fact,  weighing  the  evidence,  pro  and  by  able  specialists  in  various  branches.  AH  depart- 
eon,  accordingly.  A  considerable  amount  of  new  ments  of  the  vast  and  ever-increasing  literature  of 
material  has  been  introduced,  and  altogether  the  the  science  have  been  drawn  upon  for  their  most 
distinguished  author  has  reason  to  be  satisfied  recent  expressions.  The  late  advances  made  in 
that  he  has  placed  the  work  fully  abreast  of  the  surgical  practice  have  been  carefully  noted,  such 
state  of  our  knowledge. — Med.  Record,  Nov.  18, 1882.  |  as  ttie  recent  developments  of  Listerism  and  the 
We  have  purposely  abstained  from  comment  or  \  improvements  in  gyniEcological  operations.  In 
criticism  of  the  book  before  us.  It  has  formerly  j  every  respect  the  work  reflects  lasting  credit  on 
been  noticed  more  than  once  in  our  columns,  and  it  American  medical  literature. — Medical  andSurffieai 
is  enough  now  to  remark  that  the  present  edition  I  Reporter.  Nov.  11, 1882. 


ASHHURST,  JOHJV,  Jr.,  M.  J)., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

The  Principles  and  Practice  of  Surgery.  Third  edition,  enlarged  and  re- 
vised. In  one  large  and  handsome  octavo  volume  of  1060  pages,  with  555  illustrations. 
Cloth,  $6 ;  leather,  $7 ;  very  handsome  half  Russia,  raised  bands,  §7.50. 

Dr.  Ashhurst's  Surgerjj  is  a  condensed  treatise  i  the  work  must  be    its  best  claim  for  continued 
covering  the  whole  domain  of  the  science  in  one 


manageable  volume.  The  present  edition  has  had 
a  thorough  revision.  The  novelties  in  surgical 
practice  and  the  recent  observations  in  surgical 
science  have  been  incorporated,  but  the  size  of  the 
volume  has  not  been  materially  increased.  The 
author's  arrangement  is  perspicuous,  and  his 
language  correct  and  clear.  An  excellent  index 
closes  the  work,  and  on  the  whole  we  consider  it 
the  best  system  of  surgery  in  one  volume  which 
could  be  named  as  the  product  of  an  American 
author. — Medical  and  Surgical  Reporter,  Oct.  28,  '82. 

The  author,  long  known  as  a  thorough  student 
of  surgery,  and  one  of  the  most  accomplished 
scholars  in  the  country,  aims  to  give  in  this  work 
"a  condensed  but  comprehensive  description  of 
the  modes  of  practice  now  generally  employed  in 
the  treatment  of  surgical  affections,  with  a  plain 
exposition  of  the  principles  upon  which  these 
modes  of  practice  are  based."  In  this  he  has  so 
well  succeeded  that  it  will  be  a  surprise  to  the 
reader  to  know  how  much  practical  knowledge  ex- 
tending over  such  a  wide  range  of  research  is  com- 
pressed in  a  volume  of  this  size.    This  feature  of 


popularity  with  students  and  practitioners.  In 
fact,  in  tliis  respect  it  is  without  an  equal  in  any 
language.  In  the  present  edition  many  novelties 
in  surgical  practice  are  introduced,  manj'  modifi- 
cations of  previous  statements  made,  and  several 
new  illustrations  added.— il/ed.  Rec,  Nov.  18, 1882. 

It  treats  in  a  very  thorough  and  satisfactory 
manner  all  the  subjects  in  the  various  departments 
of  surgery.  The  medical  student  and  general  prac- 
titioner of  medicine  will  find  it  admirably  adapted 
to  their  wants,  the  former  as  a  text-book,  and  the 
latter  as  a  most  valuable  work  of  reference  when 
he  wishes  to  refresh  his  mind  and  obtain  the  latest 
information  on  any  subject  of  surgery.  While 
there  are  no  omissions  or  abridgements  of  any 
description  or  discussions  essential  for  imparting 
a  thorough  knowledge  of  any  principle  or  practice, 
yet  unnecessary  details  and'lengthy  statements  of 
views  of  various  writers  are  excluded.  In  revising 
his  work  for  a  third  edition,  the  author  has  spared 
no  pains  to  render  it  worthy  of  a  continuance  of 
the  favor  with  which  it  has  heretofore  been  re- 
ceived. We  predict  an  increasing  demand  for 
the  work.     Cincinnati  Medical  News,  Nov.,  1882. 


In  one  hand- 


GIBJS^EY,  V.  JP.,  M.  J>. 

Surgeon  to  the  Orthopwdie  Hospital,  New  York,  etc. 
Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students, 
some  octavo  volume,  profusely  illustrated.     Preparing. 

MOBBJRTS,  JOHN  B.,  A.  31.,  M.  JX^ 

Lecturer  on  Anatomy  and  on  Operative  Surgery  at  the  Philadelphia  School  of  Anatomy. 

The  Principles  and  Practice  of  Surgery.  For  the  use  of  Students  and 
Practitioners  of  Medicine  and  Surgerj'.  In  one  verj'  handsome  octavo  volume  of  about  500 
pages,  with  many  illustrations.     Preparing. 

BELLA3IY,  BBWABD,  F.  B.  C.  S. 

Operative  Surgery.   In  active  preparation.   See  Students'  Series  of  Manvxds,  page  5. 

STI3ISOJ\,  LBWIS  A.,  B.  A.,  31.  !>., 

Prof,  of  Pathol.  Anat.  at  the  Univ.  of  the  City  of  New  York,  Surgeon  and  Curator  to  Bellevue  Hosp. 
A  Manual  of  Operative  Surgery.     In  one  very  handsome  royal  12mo.  volume 
of  477  pages,  with  332  illustrations.     Cloth,  $2.50. 

This  volume  is  devoted  entirely  to  operative  sur-  every  student  should  possess  one.  This  work 
gery,  and  is  intended  to  familiarize  the  student  does  away  with  the  necessity  of  pondering  over 
witti  the  details  of  operations  and  the  different  larger  works  on  surgery  for  descriptions  of  opera- 
modes  of  performing  them.  The  work  is  hand-  tions,  as  it  presents  in  a  nutshell  what  is  wanted 
eomely  illustrated,  and  the  descriptions  are  clear  by  the  surgeon  without  an  elaborate  search  to 
and  well-drawn.    It  is  a  clever  and  useful  volume;    find  it. — Maryland  Medical  Journal,  August,  1878. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Siirg-ery. 


21 


BRYAWT,  THOMAS,  F,  B.  C,  S., 

Surgeon  to  Guy''s  Hospital,  London. 
The  Practice  of  Surgery.  Third  American  from  the  third  and  revised  English 
edition.  Thoroughly  revised  and  much  improved,  by  John  B.  Roberts,  A.  M.,  M.  D., 
Lecturer  on  Anatomy  and  Operative  Surgery  in  the  Philadelphia  Academy  of  Surgery. 
In  one  large  and  very  handsome  imperial  octavo  volume  of  10U9  pages,  with  735  illustrar 
tions.     Cloth,  §6.50;  leather,  $7.50;  very  handsome  half  Russia,  raised  bands,  $8.00. 

Without  freighting  his  book  with  multiplied  de-  [  plans  of  treatment,  etc.,  to  make  the  surgeon  who 
tails  and  wearying  descriptions  of  allied  methods  ;  follows  the  text  successful  in  his  diagnosis  and 
of  procedure,  he  is  ample  enough  for  reference  on  ;  treatment  in  any  case  in  whicli  success  can  be  se- 
al! the  departments  of  surgerj',  not  omittinj:  such  |  cured,  according  to  the  present  state  of  the  sur- 
strict  specialties  as  dental,  o"phthalmic,  military,  j  gical  art. —  Virginia  Medical  Monthly,  M&y,lSSi\. 
orthopiedic  and  gynieeological  surjjery.    Some  of 


these  chapters  are  written  by  specialists  in  these 
respective  branches,  and  all  are  amply  sufficient 
for  anyone  noi  himself  aiming  at  special  practice. 
The  labors  of  the  American  editor  deserve  un- 
qualified praise.    His  additions    to   the  author's 


It  is  a  work  especially  adapted  to  the  wants  of 
students  and  practitioners.  It  affords  instruction 
in  sufficient  detail  for  a  full  understanding  of  sur- 
gical principles  and  the  treatment  of  surgical  dis- 
eases.   It  embraces  in  its  scope  all  the  diseases 


text  are  numerous,  judicious  and  germane.    They  j  t''^^'*'■^  recognized  as  belonging  to  surgery,  and 


add  very  distinctly  to  the  value  of  the  original 
treatise,  and  give  a  more  equitable  illustration  of 
the  part  taken  by  .\meriean  surgeons  than  the 
author  was  able  to  do. — Medical  and  Surgical  lie- 
porter,  Feb.  12, 1881. 

It  is  the  best  of  all  the  one-volume  works  on  sur- 
gery of  recent  date  for  the  ordinary  surgeon,  con- 
taining enough  of  pathology,  accurate  description 
of  surgical    diseases   and  "injuries,    well-devised 


all  traumatic  injuries.  In  discussing  these  it  has 
seemed  to  be  the  aim  of  the  author  rather  to  pre- 
sent the  student  with  practical  information,  and 
that  alone,  than  to  burden  his  memory  with  the 
views  of  different  writers,  however  distinguished 
they  might  have  been.  In  this  edition  the  whole 
work  has  been  carefully  revised,  much  of  it  lias 
been  rewritten,  and  important  additions  have  been 
made  to  almost  every  cnapter. — Cincinnati  Medical 
yews,  Jan.  1881. 


EBICHSEN,  JOHN  E.,  F.  B.  S,,  F,  B.  C,  S., 

Professor  of  Surgery  in  University  College,  London,  etc. 
The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.      Specuilly  revised  by  the  Author  from  the  eighth  and  enlarged. 
English   edition.     In  two  large  and  beautiful  octavo  volumes  of  about  2000  pages,  illus- 
trated with  about  900  engravings  on  wood.     Preparing. 
A  few  notices  of  the  previous  edition  are  appended 

His  polished,  clear  style,  his  freedom  from  pre- 
judice and  hobbies,  his  unsurpassed  grasp  of  his 
subject  and  vast  clinical  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we 
wish,  at  the  least  cost  of  time,  to  learn  the  most  of 
a  topic  in  surgery,  we  turn,  by  preference,  to  his 
work.  It  is  a  pleasure,  therefore,  to  see  that  the 
appreciation  of  it  is  general. — Medical  and  Surgical 
Reporter,  Feb.  2,  1878. 

For  the  past  twenty  years  Erichsen's  Surgery 
has  maintained  its  place  as  the  leading  text-book, 


not  only  in  this  country,  but  in  Great  Britain. 
That  it  is  able  to  hold  its  ground  is  abundantly 
proven  by  the  thoroughness  with  which  the  pres- 
ent edition  has  been  revised,  and  by  the  largo 
amount  of  valuable  material  that  has  been  added. 
Aside  from  this,  one  hundred  and  fifty  new  illus- 
trations have  been  inserted,  including  quite  a 
number  of  microscopical  appearances  of  patholo- 
gical processes.  So  marked  is  this  change  for  the 
better  that  the  work  almost  appears  as  an  entirely 
new  one. — Medical  Record,  Feb.  23, 1878. 


ESMABCH,  Dr.  FBIEDBICH, 

Professor  of  Surgery  at  the  University  of  Kiel,  etc. 

Early  Aid  in  Injuries  and  Accidents.     Five  Ambulance  Lectures.    Trans- 
lated by  H.  R.  II.  Princess  Christian.    In  one  handsome  small  12mo.  volume  of  109 

pages,  witli  24  illustrations.     Cloth,  75  cents.     Just  ready. 


The  excellent  little  handbook  by  Dr.  Esmarch 
may  be  referred  to  by  all  for  clear,  safe  and  practi- 
cal directions  and  instructions  for  rendering  the 
right  kind  of  aid  until  the  doctor  arrives,  in  the 
event  of  the  numerous  injuries  that  are  liable  to 
happen  in  a  family  or  neighborhood  in  the  circum- 
stances of  daily  life.  The  manual  is  earnestly 
andjustly  commended  for  its  excellence  and  clear- 
ness, and  especially  for  the  minuteness  and  extent 
of  its  practical  details. — Harpers'  Magazine,  Aug., 
1883. 


organization  of  the  human  body,  illustrated  by 
clear,  suitable  diagrams.  The  .second  teaches  how 
to  give  judicious  help  in  ordinary  injuries — contu- 
sions, wounds,  haemorrhage  and  poisoned  wounds. 
The  third  treats  of  first  aid  in  cases  of  fracture 
and  of  dislocations,  in  .sprains  and  in  burns.  Next, 
the  methods  of  affording  first  treatment  in  cases 
of  fro.st-bite,  of  drowning,  of  suffocation,  of  loss  of 
consciousness  and  of  poisoning  are  described; 
and  the  fifth  lecture  teaches  how  injured  persons 
may  be  most  safely  and  easily  transported  to  their 


The  course  of  instruction  is  divided  into  five  liomes,  to  a  medical  man,  or  to  a  hospital.  The 
sections  or  lectures.  The  first,  or  introductory  j  illustrations  in  the  book  are  clear  and  good. — Medi- 
lecture,  gives  a  brief  account  of  the  structure  and  ;  cal  Times  and  Gazette,  Nov.  4, 1882. 


nBTJITT,  BOBEBT,  M,  B,  C,  S.,  etc. 

The  Principles  and  Practice  of  Modern  Surgery.     From  the  eighth 
London  edition.     In  one  Svo.  volume  of  687  pages,  with  432  illus.     Clotli,  $4 ;  leather,  $5. 


SARGENT  ON  BANDAGING  and  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition, 
with  a  Chapter  on  military  surgerj-.  One  12mo. 
volume  of  383  pages,  with"l87  cuts.    Cloth,  S1.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 
one  Svo.  vol.  of  G88  pages,  witli  340  illustrations. 
Cloth,  83.75. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  from  the  last  Edinburgh 
edition.  In  one  large  8vo.  vol.  of  682  pages,  with 
304  illustrations.    Cloth,  $3.75. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OP 
SURGERY.  Edited  by  John  Nf.ill,  M.  D.  In 
one  Svo.  vol.  of  784  pp.  with  31G  illus.    Cloth,  83.75. 

COOPER'S  LECTURES  ON  THE  PRINCIPLES 
AND  PRACTICE  OF  SURGERY.  In  one  Svo.voL 
of  7G7  pages.    Cloth,  S2.00. 

SKEY'S  OPERATIVE  SURGERY.  In  one  vol.  8va 

of  661  pages,  with  81  woodcuts.    Cloth,  S3.25. 

GIBSON'S  INSTITUTES    AND    PRACTICE    OP 
SURGERY.  Eighth  edition.    In  two  octavo  Tola. 
•      of  965  pages,  with  34  plates.    Leather  86.50. 


22  Henry  C.  Lea's  Son  &  Co.'s  Publications — Sui-gery. 

HOLMES,  TIMOTHY,  M.  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  be-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  and  St.  Joseph's  Hospitals, 
Philadelphia,  assisted  by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes  containing  3187  double- 
columned  pages,  with  979  illustrations  on  wood  and  13  litliographic  plates,  beautifully 
colored.  Price  per  volume,  cloth,  $6.00 ;  leather,  $7.00 ;  half  Russia,  $7.50.  Per  set,  cloth, 
$18.00 ;  leather,  $21.00 ;  half  Russia,  $22.50.     Sold  only  by  subscription. 

Volume  I.  contains  General  Pathology,  Morbid  Processes,  Injuries  in  Ges- 
eral,  Complications  of  Injuries  and  Injuries  of  Regions. 

Volume  II.  contains  Diseases  of  Organs  op  Special  Sense,  Circulatory  Sys- 
tem, Digestive  Tract  and  Genito-Urinary  Organs. 

Volume  HI.  contains  Diseases  of  the  Respiratory  Organs,  Bones,  Joints  and 
Muscles,  Diseases  of  the  Nervous  System,  Gunshot  Wounds,  Operative  and 
Minor  Surgery,  and  Miscellaneous  Sutjjects  (including  an  essay  on  Hospitals). 

This  great  work,  issued  some  years  since  in  England,  has  won  such  universal  confi- 
dence wherever  the  language  is  spoken  that  its  republication  here,  in  a  form  more 
thoroughly  adapted  to  the  wants  of  the  American  practitioner,  has  seemed  to  be  a  duty 
owing  to  the  profession.  To  accomplish  tliis,  each  article  has  been  placed  in  the  hands  of 
a  gentleman  specially  competent  to  treat  its  subject,  and  no  labor  has  been  spared  to  bring 
each  one  up  to  the  foremost  level  of  the  times,  and  to  adapt  it  thoroughly  to  the  practice 
of  the  country.  In  certain  cases  this  has  rendered  necessary  tlie  substitution  of  an  entirely 
new  essay  for  the  original,  as  in  the  case  of  the  articles  on  Skin  Diseases  and  on  Diseases 
of  the  Absorbent  System,  where  the  views  of  the  authors  have  been  superseded  by  the 
advance  of  medical  science,  and  new  articles  have  therefore  been  prepared  by  Drs.  Arthur 
.  Van  Harlingen  and  S.  C.  Busey,  respectively.  So  also  in  the  case  of  Anresthetics,  in  the  use 
of  which  American  practice  differs  from  that  of  England,  the  original  has  been  supple- 
mented with  a  new  essay  by  J.  C.  Reeve,  M.  D.  The  same  careful  and  conscientious 
revision  has  been  pursued  throughout,  leading  to  an  increase  of  nearly  one-fourth  in 
matter,  while  the  series  of  illustrations  has  been  nearly  trebled,  and  the  whole  is  presented 
as  a  complete  exponent  of  British  and  American  Surgery,  adapted  to  the  daily  needs  of 
the  working  practitioner. 

In  order  to  bring  it  within  the  reach  of  every  member  of  the  profession,  the  five  vol- 
umes of  the  original  have  been  compressed  into  three  by  employing  a  double-columned 
royal  octavo  page,  and  in  this  improved  form  it  is  offered  at  less  than  one-half  the  price  of  the 
original.  It  is  printed  and  bound  to  match  in  every  detail  with  Reynolds'  System  of  Medi- 
cine. The  work  will  be  sold  by  subscription  only,  and  in  due  time  every  member  of  the 
profession  will  be  called  upon  and  offered  an  opportunity  to  subscribe. 

The  authors  of  the  original  English  edition  are  r      Great  credit  is  due  to  the  American  editor  and 

men  of  the  front  rank  in  England,  and  Dr.  Packard  |  his  co-laborers  for  revising  and  bringing  within 

has  been  fortunate  in  securing  as  his  American  ;  easy  reach  of  American  surgeons  a  work  which  has 

coadjutors  such  men  as  Bartholow,  Hyde,  Hunt,  been  received  with  such  universal  favor  on  the 

Conner,    Stimson,    Morton,  Hodgen,  Jewell    and  1  -other  side  of  the  Atlantic  as  Holmes'  System  of 

their  colleagues.    As  a  whole,  tlie  work  will  be  |  Surgery.    With  regard  to  the  mechanical  execu- 

solid  and  substantial,  and  a  valuable  addition  to  tion  of  the  work,  neither  pains  nor  money  seem 

the  library  of  any  medical  man.    It  is  more  wieldly  |  to  have  been  spared  by  the  publishers. — Med.  and 

and  more  useful  than  the  English  edition,  and  with  I  Surg.  Reporter,  Sept.  14, 1881. 

Ite  companion  work-"  Reynolds'  System  of  Medi-  i      j^  the  revision  of  the  work  for  the  American 

=iL    -will  well  represent  the  present  state  of  our  '  e^jji^n  not  only  has  provision  been  made  for  a 

-•UK   V  ^T       u  f  ^''"?"*';  wit'i  t'i?^e  two  works  ;  recognition  of  tlie  advances  made  in  our  knowledge 

will  be  fairly  well  furnished  bead-wise  and  hand-  ^^^^^     ^^e  ten  years  since  its  first  publication, 

miso.-The  Medical  ^ews,3&n.^,n»2.  |  ^ut  also  for  a  presentation  of  the  variations  in 

This  work  is  cyclopsedic  in  character,  and  eveiy  i  practice  which  characterize  American  surgery  and 

subject  is  treated  in  an  exhaustive  manner.    It  is  distinguish  it  from  that  of  Great  Britain.    The 

especially  designed  for  a  reference  book,  which  '  work   is   one   which  we  take    pleasure   in  com- 

every  practising  surgeon  should  have  under  hand  ,  mending  to  the  notice  of  our  readers  as  an  ency- 

in  cases  which  require  more  than  ordinary  knowl-  !  clopsedia  of  surgical  knowledge   and  practice. — 

edge. — Chicago  Med.  Journ.  and  Exam.,  Feb.  1882.  !  St.  Louis  Courier  of  Medicine,  Nov.  1881. 


HAMILTON,  FBAJST^  H,,  31,  !>.,  ZZ.  D., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Sixth  edition, 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  909 
pages,  with  352  illustrations.     Cloth,  $5.50;  leather,  $6.50 ;  half  Russia,  raised  bands,  $7.00. 

work  in  his  own  or  any  language  on  fractures  and 
dislocations. — Lond.  Med.  Times  and  Gaz.  Nov.  19,  '81. 


The  only  complete  work  on  its  subject  in 
the  English  tongue,  and  indeed  it  may  now  be 
«aid  to  be  the  only  work  of  its  kind  in  any 
tongue.  It  would  require  an  exceedingly  critical 
examination  to  detect  in  it  any  particulars  in 
which  it  might  be  improved.  The  work  is  a  mon- 
ament  to  American  surgerVj  and  will  long  serve  to 
keep  green  the  memory  ot  its  venerable  author. — 
Michigan  Medical  News,  Nov.  10, 1881. 

Dr.  Hamilton  is  the  author  of  the  best  modern 


The  work  as  a  whole  is  one  of  the  very  few 
medical  books  of  American  origin  that  are  every- 
where accorded  a  standard  character,  its  suD- 
ject-matter  unavoidably  comes  home  to  every 
general  practitioner  as  a  branch  of  our  art  in 
which  he  cannot  afford  to  neglect  the  fullest  and 
most  practical  information  of  such  a  character  as  it 
and  it  alone  furnishes. — N.  Y.  Med.  Jour.,  March,'81. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ^Frac,  Disloc,  Ophthal.   23 


8TIMSON,  LJEWIS  A.,  B.  A.,  M,  D., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York,  Surgeon  and  Curator 
to  iellevue  Hospital,  Surgeon  to  the  Presbyterian  Hospital,  Keio  York,  etc. 

A  Practical  Treatise  on  Fractures.     In  one  very  handsome  octavo  volume  of 
598  pages,  with  360  beautiful  illustrations.     Cloth,  $4.75  ;  leather,  $5.75. 
The  author  gives  in  clear  language  all  that  the  j      The  author  has  given  to  the  medical  profession 


practical  surgeon  need  know  of  the  science  of 
fractures,  their  etiology,  symptoms,  processes  of 
union,  and  treatment,  according  to  the  latest  de- 
velopments. On  the  basis  of  mechanical  analysis 
the  author  accurately  and  clearly  explains  the 
ciinical  features  of  fractures,  and  by  the  same 
method  arrives  at  the  proper  diagnosis  snd  rational 
treatment.  A  thorough  explanation  of  tiie  patho- 
logical anatomy  and  a  careful  description  of  the 
various  methods  of  procedure  make  the  book  full 
of  value  for  every  practitioner.    The  diction  is 


in  this  treatise  on  fractures  what  is  likely  to  be- 
come a  standard  work  on  the  subject.  It  is  certainly 
not  surpassed  by  any  work  written  in  the  English, 
or,  for  that  matter,  any  other  language.  The  au- 
thor tells  us  in  a  short,  concise  and  comprehensive 
manner,  all  that  is  known  about  his  subject.  There 
is  nothing  scanty  or  superficial  about  it,  as  in  most 
other  treatises ;  on  the  contrary,  everything  is  thor- 
ough. The  chapters  on  repair  of  fractures  and  their 
treatment  show  him  not  only  to  be  a  profound  stu- 
dent, but  likewise  a  practical  surgeon  andpatholo- 


simple,  clear  and  vivid.  Wherever  desirable,  brief  ;  gist.  His  mode  of  treatment  of  tl'ie  ditFereht  fract- 
clinical  hi.-'tories  are  introducted,  which,  being  ;  uresis  eminently  sound  and  practical.  Sveconsider 
skillfully  chosen  to  illustrate  particular  points,  |  this  work  one  of  the  be.st  on  fractures ;  and  it  will 
attest  the  rich  experience  of  the  author.  The  i  be  welcomed  not  only  as  a  text-book,  but  also  by 
numerous  beautifully-executed  illustrations  form  I  the  surgeon  in  full  practice. — K.  O.  Medical  arid 
an  especial  attraction  of  tlie  book. — Centralblatt  I  Surgical  Journal,  Marcli,  1883. 
fur  Chirurgie,  May  19,  1883.  I 

WBLLS,  J.  SOBLBBnG,  F,  M,  C,  S., 

Professor  of  Ophthalmology  in  King's  College  Hospital,  London,  etc. 

A  Treatise  on  Diseases  of  the  Eye.  Fourth  American  from  the  third  London 
edition.  Tlioroughly  revised,  with  copious  additions,  by  Charles  S.  Bull,  M.D.,  Surgeon 
and  Pathologist  to  the  New  York  Eye  and  Ear  Infirmary.  In  one  large  and  very  hand- 
some octavo  volume  of  822  pages,  with  257  illustrations  on  wood,  six  colored  plates,  and 
selections  from  the  Test-types  of  Jaeger  and  Snellen.  Cloth,  $5.00 ;  leather,  $6.00 ; 
very  handsome  half  Russia,  raised  bands,  $6.50.      Just  ready. 


The  present  edition  appears  in  less  than  three 
years  since  the  publication  of  the  last  American 
edition,  and  yet,  from  the  numerous  recent  inves- 
tigations that  have  been  made  in  tliis  braneli  of 
medicine,  many  changes  and  additions  have  been 
required  to  meet  the  present  scope  of  knowledge 
upon  this  subject.  A  critical  examination  at  once 
shows  the  fidelity  and  thoroughness  with  which 
the  editor  has  accomplished  his  part  of  the  work. 
The  illustrations  throughout  are  good.  This  edi- 
tioti  can  be  recommended  to  all  as  a  complete 
treatise  on  diseases  of  the  eye,  than  which  proba- 
bly none  better  exists. — Medical  Record,  Aug.  18,  '83. 

This  magnificent  work  is  par  excellence  the 
standard  work  of  the  times  on  the  important  sub- 
jects of  which  it  treats.  It  is  absolutely  necessary 
for  tlie  physician  to  have  an  acquaintance  with  the 
pathology'and  therapeutics  of  the  eye.  From  no 
source  can  he  more  accurately  derive  this  needed 
knowledge  than  from  the  volume  before  us. — 
Medical  and  Surgical  Reporter,  August  4, 1883. 

Anyone  desirous  of  obtaining  the  most  con(- 


plete  work  on  diseases  of  the  eye  in  the  English 
language,  will  find  in  thi.s  treatise  the  fulfilment 
of  that  desire.  Dr.  Bull's  additions  to  the  volume 
may  be  taken  as  a  brief  but  verv  excellent  resurni 
of  the  progress  made  in  ophtVialmology  during 
the  past  ten  years.  It  is  no  exaggeration  to  sajr 
that  there  are  few  more  readable  books  in  medi- 
cine than  this;  certainly  no  medical  library  can 
be  considered  complete  without  it. — Canada  Medi- 
cal and  Surgical  Journal,  November,  1883. 

The  issue  of  a  fourth  American  edition  of  this 
work  within  three  years  of  the  third,  shows  how 
favorably  it  has  been  received  by  the  medical  pro- 
fession at  large.  We  must  congratulate  the  editor 
on  his  clearness  and  conciseness  in  laying  down 
rules  for  treatment  and  the  proper  remedies  to  be 
used  in  every  case.  This  work  must  be  pro- 
nounced the  most  complete  text-book  on  the  sub- 
ject, and  merits  careful  perusal  by  the  student  as 
well  as  the  practitioner,  while  to  the  specialist  it 
will  be  found  an  easy  and  faithful  book  of  refer- 
ence.— Cincinnati  Lancet  and  Clinic,  August  18, 1838. 


NETTLBSHIP,  EDWABD,  F,  M.  C,  S,, 

Ophthalmic  Surg,  and  Lect.  on  Ophth.  Surg,  at  St.  Thomas''  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  New  edition.  With  a  chap- 
ter on  the  Detection  of  Color-Blindness,  by  William  Thomson,  M.  D.,  Ophthalmologist 
to  tlie  Jefferson  Medical  College.  In  one  royal  12mo.  volume  of  416  pages,  with  138 
illustrations.     Cloth,  $2.00.     Just  ready. 

This  admirable  guide  bids  fair  to  become  the  i  been  received  shows  its  real  value  and  the  appre- 
favorite  text^book  on  ophthalmic  surgery  with  stu-  !  elation  by  the  profession  of  its  intrinsic  merits, 
dents  and  general  practitioners.  It  bears  through-  j  Dr.  Tliomson  has  added  a  Chapter  on  Color-Blind- 
out  the  imprint  of  sound  judgment  combined  with  |  ness,  on  which  subject  his  extensive  investigations 

VQC+  <i vrvorif*rmo       The   illUStratlollS   are  numerous      avt*  \p^11  Vnnivn        WilVi    fViia   VQlnaKlft   flHrlitlrtTl  t.llA 

Tliis  book,  within  the  short  com 


vast  experience 

and  well  chosen 

pass  of  about  400  pages,  contains  a  lucid  exposition 

of  the  modern  aspect  of  ophthalmic  science. — 

Medical  Record,  June  23,  1883. 

This  work  is  essentially  a  student's  manual  of 
ophthalmology,  and  the  favor  with  which  it  has 


are  well  known.  With  this  valuable  addition  the 
book  becomes  the  most  valuable  guide  to  diseases 
of  the  eye  yet  published.  We  commend  it  to  the 
notice  of  students  of  medicine,  and  to  such  prao- 
titioners  as  desire  a  condensed  treatise  on  a  class 
of  diseases  which  are  frequently  met  with  in  daily 
practice. — Buffalo  Med.  and  Siirg.  Journ.,  May,  1883. 


BMO  WJSTF,  FDGAB  A,, 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 
How  to  Use  the  Ophthalmoscope.     Being  Elementary  Instructions  in  Oph- 
thalmoscopy, arranged  for  the  use  of  Students.     In  one  small  royal  12mo.  volume  of  116 
pages,  with  35  illustrations.     Cloth,  $1.00. 


LAVVSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
AND  EYELIDS:  Their  Immediate  and  Remote 
Effects.    8  vo.,  4t)4  pp.,  92  illus.    Cloth,  $5-50. 

LAURENCE  AND  MOON'S  HANDY  BOOK  OF 
OPHTHALMIC  SURGERY,  for  the  use  of  Prac- 


titioners.   Second  edition.    In  one  octavo  vol- 
ume of  227  pages,  with  65  illust.    Cloth,  $2.76. 
CARTER'S  PRACTICAL  TREATISE  ON  DISEAS- 
ES OF  THE  EYE.    Edited  by  John  Ghmw,  M.D. 
In  one  handsome  octavo  volume. 


24     Henry  C.  Lea's  Son  &  Co.'s  Publications — Otol.,  Dent.,  Urin.  Dis. 
POLITZER,  ADAM, 

Imperial- Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna.    • 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, by  James  Patterson  Cassells,  M.  D.,  M.  R.  C.  S.  In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.     Cloth,  $5.50.     Just  ready. 

Professor  Politzer's  well-known  reputation  as  one 
of  the  first  authorities  on  diseases  of  the  ear  will 


'ead  the  reader  to  expect  something  more  than  an 
ordinary  text-book  in  a  work  that  bears  his  name, 
and  he  "will  not  be  disappointed.  The  anatomy, 
physiology,    pathology,    therapeutics   and    bibfi- 


has  ever  appeared,  systematic  without  being  too 
diffuse  on  obsolete  subjects,  and  eminently  prswj- 
tical  in  every  sense.  The  anatomical  descriptions 
of  each  separate  division  of  the  ear  are  admirable, 
and  profusely  illustrated  by  woodcuts.  Thev  are 
followed   immediately  by  the  physiology  of  the 


ography  of  the  ear  are  so  ably  and  thoroughly  pre-  section,  and  this  again  by  the  pathological  physi- 
sented,  that  he  who  has  carefully  read  this  imposing  :  ology.an  arrangement  which  serves  to  keep  upthe 
volume  can  feel  sure  that  very  little  of  interest  or  !  interest  of  the  student  by  showing  the  direct  ap- 
value  in  the  past  or  present'of  aural  surgery  has  !  plication  of  what  has  preceded  to  the  study  of  dis- 
eseaped  him. — Am.  Jour,  of  the  Med.  Sciences,  July,  I  ease.  The  whole  work  can  be  recommen(Jed  as  a 
1883.  I  reliable  guide  to  the  student,  and  an  efficient  aid 

The  work  itself  we  do  not  hesitate  to  pronounce  '  to  the  practitioner  in  his  treatment. — Boston  Mec^ 
the  best  upon  the  subject  of  aural  diseases  which  i  cal  and  Surgical  Journal,  June  7, 1883. 


BVRJSrETT,  CHARLES  S.,  A.  M,,  M,  D., 

Aural  Surg,  to  the  Presb.  Hasp.,  Snrgeon-in-charge  of  the  Infir.for  Dis.  of  the  Ear,  Philadelphia. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  New  edition.  In  one  liandsome  octavo 
volume  of  about  700  pages,  with  about  100  illustrations. 

A  notice  of  the  previous  edition  is  appended. 


The  medical  profession  will  welcome  this 
work  on  otology,  which  presents  clearly  and  con- 
cisely its  present  aspect,  whilst  clearly  indicating 
the  direction  in  which  further  researches  can  be 
most  profitably  carried  on.    Dr.  Burnett  has  pro- 


duced a  work  which,  as  a  text-book,  stands  faeiU 
princeps  in  our  language.  To  the  specialist  the 
work  IS  of  the  highest  value. — Edinburgh  Med.  Jour ^ 
Aug.  '78. 


COLJEMAW,  A,,  i.  M,  C.  J*.,  F.  12.  C.  S.,  Exam.  L.  D,  S,, 

Senior  Dent.  Surg,  and  Led.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hosp.,  London, 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  Stellwagex,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  at  tlie  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 

This  volume  deserves  to  rank  among  the  most  :  deserves  a  place  in  the  library  of  every  dentist, 
important  of  recent  contributions  to  dental  litera-    — Dental  Cosmos^  May,  1882. 

ture.  Jlr.  Coleman  has  presented  his  methods  of  !  It  should  be  ui  the  possession  of  everv  practi- 
practice,  for  the  most  part,  in  a  plain  and  concise  I  tioner  in  this  country.  The  part  devoted  to  first 
manner,  and  the  work  of  the  American  editor  has  and  second  dentition  and  irregularities  in  the  per- 
been  conscientiously  performed.  He  has  evidently  |  nianent  teeth  is  fully  worth  the  price.  In  tact, 
labored  to  present  his  convictions  of  the  best  modes  |  price  should  not  be  considered  in  purchasing  such 


of  practice  for  the  instruction  of  those  commenc- 
ing a  professional  career,  and  he  has  faithfully  en- 
deavored to  teacli  to  others  all  that  he  has  acquired 
by  his  own  observation  and  experience.    Tlie  book 


a  work.  If  tlie  money  put  into  some  of  our  so-called 
standard  text-books  could  be  converted  into  such 
publications  as  this,  much  good  would  result. — 
Southern  Dental  Journal,  May,  1882. 


GMOSS,  S.  J).,  M.  X).,  ii.  D.,  J).  C.  X.,  etc, 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel,  W.  Gkoss,  M.  D.,  Surgeon  to  the  Philadelphia 
Hospital.     In  one  octavo  volume  of  574  pages,  with  170  illustrations.     Cloth,  $4.50. 

For  reference  and  general  information,  the  phy-  I  sual  advantage  of  being  easily  comprehended  by 
sician  or  surgeon  can  find  no  work  that  meets  their    the  reasonable  and  practical  manner  in  which  the 
necessities  more  thoroughly  than  this,  a  revised    various  subjects  are  systematized  and  arranged, 
edition  of  an  excellent  treatise.  Replete  with  hand-    — Atlanta  Medical  Journal,  Oct.,  187C. 
some  illustrations  and  good  ideas,  it  has  the  unu-  1 


ROBERTS,  WILLIAM,  M.  J>., 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  fourth  London  edition.  Illustrated  by 
numerous   engravings.     In  one  large  and  handsome  octavo  volume.     Preparing. 

TM03IRS0JSr,  SIR  HENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.     In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.     Cloth,  $2.25. 

By  the  Same  Author. 

On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Pistulae.  From  the  third  English  edition.  In  one  volume  of  359  pages,  with 
47  cuts  and  3  plates.     Cloth,  $3.50. 

BASHAM    on    renal    DISE.'VSES:   A  Clinical    I    one  12mo.  vol.  of  304  pages,  with  21  illustrationa. 
Guide  to  their  Diagnosis  and    Treatment.    In    |    Cloth,  $2.00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — ^Venereal  Dis.,  etc.      25 


BTIMSTEAn,  F.  J.,  mid  TAYLOB,  It.  7F., 

31,  -D.,  LL.  D.,  A.  M,,  31.  JD., 

Late  Professor  of  Venerea!  Diseases  Surgeon  to  Charity  Kospiial,  New  York,  Prof,  of 

at    the    College   of   Physicians    and  Venereal  and  Skin  Diseases  in  the  University  of 

Surgeons,  Neiv  York,  etc.  Vermont,  Pres.  of  the  Am.  Dennatological  A&s'n, 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Fiftli  edition,  revised  and  largely  re- 
written, by  Dr.  Taylor.  In  one  large  and  handsome  octavo  volume  of  about  898  pages 
with  139  illustrations,  and  thirteen  chromo-lithographic  figures.  Cloth,  $4.75;  leather, 
$5.75 ;  very  handsome  half  Russia,  $6.25. 

Excerpt  from  the  Preface  to  the  Fifth  Edition. 

In  this  edition  I  have  carefully  revised  the  text,  and,  when  necessary,  have  changed 
and  modified  it,  and  I  have  endeavored  to  bring  it  up  to  our  present  state  of  knowledge  in 
all  particulars.  ^luch  new  matter  will  be  found  relating  to  therapeutics,  and  a  chapter 
on  syphilis  and  marriage  has  been  appended. 

This  admirable  boolc  is  undoubtedly  the  best  j  known  that  it  would  be  superfluous  here  to  pass  in 
book  on  the  subject  which  has  appeared  on  this  |  review  its  general  or  special  points  of  excellence, 


side  of  the  Atlantic,  and  one  of  the  best  which  has 
appeared  anywhere.  As  years  have  rolled  by  it 
has  reached  successive  editions,  constantly  assimi- 
lating the  conclusions  of  scientific  investigations 
all  over  the  world,  and  never  falling  behind  the 
advance  guard  of  its  own  department.  This  last 
edition  keeps  up  tne  reputation  which  its  prede- 
cessors required.  It  comes  revised,  added  to  and 
improved.  It  is  in  every  way  admirable,  a  credit 
to  its  authors  and  a  credit  to  its  publishers. —  The 
Medical  News,  Dee.  22,  1883. 
Tlie  character  of  this  standard  work  is  so  well 


The  verdict  of  the  profession  has  been  passed;  it 
has  been  accepted  as  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
venereal  diseases  in  the  language;  admirable  as  a 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
successful  treatment,  it  is  an  ornament  to  the  medi- 
cal literature  of  this  country.  The  additions  made 
to  the  present  edition  are  eminently  judicious, 
from  the  standpoint  of  practical  utility. — Journal  of 
Cutaneous  and  Venereal,  Diseases,  Jan.  1884. 


cohjstl,  v., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lourcine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  William  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.     Cloth,  $3.75.     Just  ready. 


The  anatomical  and  histological  characters  of  the 
hard  and  soft  sore  are  admirably  described.  The 
multiform  cutaneous  manifestations  of  the  disease 
are  dealt  wifh  histologically  in  a  masterly  way,  as 
we  should  indeed  expect  them  to  be,  and  the 
accompanying  illustrations  are  executed  carefully 
and  well.  The  various  nervous  lesions  which  are 
the  recognized  outcome  of  the  syphilitic  dyscrasia 
are  treated  with  care  and  consideration.  Syphilitic 
epilepsy,  paralysis,  cerebral  syphilis  and  locomotor 
ataxia  are  subjects  full  of  interest;  and  nowhere  in 


the  whole  volume  is  the  clinical  experience  of  the 
author  or  the  wide  acquaintance  of  the  translators 
with  medical  literature  more  evident.  The  anat- 
omy, the  histology,  the  pathology  and  the  clinical 
features  of  syphilis  are  represented  in  this  work  in 
their  best,  most  practical  and  most  instructive 
form,  and  no  one  will  rise  from  its  perusal  without 
the  feeling  that  his  grasp  of  the  wide  and  impor- 
tant subject  on  which  it  treats  is  a  stronger  and 
surer  one. — The  London  Practitioner,  Jan.  1882. 


GROSS,  SA3rUEL  W.,  A.  31.,  M,  D., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  Second  edition,  thoroughly  revised.  In  one  very  hand- 
some octavo  volume  of  168  pages,  with  16  illustrations.     Cloth,  $1.50.     Just  ready. 

The  author  of  this  monograph  is  a  man  of  posi-  I  This  work  will  derive  value  from  the  high  stand- 
tive  convictions  and  vigorous  style.  This  is  jusli-  ing  of  its  author,  aside  from  the  fact  of  its  passing 
fied  by  his  experience  and  by  his  study,  which  has  |  so  rapidly  into  its  second  edition.  This  is,  indeed, 
gone  hand  in  band  with  his  experience.  In  regard  [  a  book  that  every  phj-sician  will  be  glad  to  place 
to  the  various  organic  and  functional  disorders  of  •  in  his  library,  to  be  read  with  profit  to  himself, 
the  male  generative  apparatus,  he  has  had    ex-  i  and  with  incalculable  benefit  to  his  patient.    Be- 


ceptional  opportunities  for  observation,  and  his 
book  shows  tliat  he  has  not  neglected  to  compare 
his  own  views  with  those  of  other  authors.  The 
result  is  a  work  which  can  be  safely  recommended 
to  both  physicians  and  surgeons  as  a  guide  in  the 
treatment  of  the  disturbances  it  refers  to.  It  is 
the  best  treatise  on  the  subject  with  which  we  are 
acquainted. — The  Medical  Neics,  Sept.  1, 1883. 


sides  the  subjects  embraced  in  the  title,  which  are 
treated  of  in  their  various  forms  and  degrees, 
spermatorrhoea  and  prostatorrhcea  are  also  fully 
considered.  The  work  is  thoroughly  practical  in 
character,  and  will  be  especially  useful  to  the 
general  practitioner. — Medical  jRecord,  Aug.  18, 
1883. 


CULLBRIEB,  A.,  &  BU3fSTEAD,  F.  J.,  31.1).,  ZL.J)., 

Surgeon  to  the  HOpital  du  Midi.         Late  Professor  o/  Venereal  Diseases  in  the  College  of  Physician* 
and  Surgeons,  Kew  York. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freeman  J.  Bum- 
stead,  M.  D.  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  plates, 
containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of  life.  Strongly 
bound  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  25  cts. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  (FORMS    OF     LOCAL     DISEASE    AFFECTING 
DISORDERS.  In  one  8vo  vol.  of  479  p.  Cloth, $3.2,5.  I  PRINCIPALLY    THE    ORGANS    OF    GENERA- 
LEE'S  LECTURES  ON  SYPHILIS  AND  SOME  I  TION.    In  one  8vo.  vol.  of  24C  pages.    Cloth,  $2.25. 


26       Henry  C.  Lea's  Son  &  Co.'s  Publications — Diseases  of  Skin. 


SrrjDB,  J,  NEVIWS,  A,  J/.,  M.  !>., 

Professor  of  Dermatology  and  Venereal  Diseajses  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  and 
Practitioners.  In  one  handsome  octavo  volume  of  570  pages,  vnih  66  beautiful  and  elab- 
orate illustrations.     Cloth,  $4.25 ;  leather,  §5.25.     Just  ready. 


The  author  has  given  the  student  and  practi- 
tioner a  work  admirably  adapted  to  the  wants  of 
each.  We  can  heartily  commend  the  boolv  as  a 
valuable  addition  to  our  literature  and  a  reliable 


cian  in  active  practice.  In  dealing  with  these 
questions  the  author  leaves  nothing  to  the  pre- 
sumed knowledge  of  the  reader,  but  enters  thor- 
oughly into  the  most  minute  description,  so  that 


guide  to  students  and  practitioners  in  their  studies  I  one  is  not  only  told  what  should  be  done  under 
and  practice. — Am.  Journ.  of  Med.  Sci.,  J u]y,\SS3.      I  given  conditions  but  how  to  do  it  as  well.     It  is 

Especially  to  be  praised  are  the  practical  sag-  |  therefore  in  the  best  sense  "a  practical  treatise." 
gestions  asto  what  may  be  called  the  common-  |  That  it  is  comprehensive,  a  glance  at  the  index 
sense  treatment  of  eczema.  It  is  quite  impossible  i  will  show. — Maryland  Medical  Journal,  July  7,  1883. 
to  exaggerate  the  judiciousness  with  which  the  Professor  Hyde  has  long  been  known  as  one  of 
formulse  for  the  external  treatment  of  eczema  are  I  the  most  intelligent  and  enthusiastic  representa- 
selected,  and  what  is  of  equal  importance,  the  full  [  tives  of  dermatology  in  the  west.  His  numerous 
and  clear  instructions  for  tiieir  use. — London  Medir  '  contributions  to  tlie  literature  of  this  specialty 
col  Tivies  ami  Gazette,  July  28, 1883.  I  have  gained  for  liim  a  favorable  recognition  as  a 

The  work  of  Dr.  Hyde  will  be  awarded  a  high  i  careful,  conscientious  and  original  observer.  The 
position.  The  student  of  medicine  will  find  it  i  remarkable  advances  made  in  our  knowledge  of 
peculiarly  adapted  to  his  wants.  Notwithstanding  diseases  of  the  skin,  especially  from  the  stand- 
the  extent  of  the  subject  to  which  it  is  devoted,  '  point  of  pathological  histology  and  improved 
yet  it  is  limited  to  a  single  and  not  very  large  vol-  methods  of  treatment,  necessitate  a  revision  of 
ume,  without  omitting  a  proper  discussion  of  the  \  the  older  text-books  at  short  intervals  in  order  to 
topics.  The  conciseness  of  the  volume,  and  the  bring  them  up  to  the  standard  demanded  by  the 
setting  forth  of  only  what  can  be  held  as  facts  will  march  of  science.  This  last  contribution  of  Dr. 
also  make  it  acceptable  to  general  practitioners.  Hyde  is  an  effort  in  this  direction.  He  has  at- 
— Cincinnati  Medical  Xews,  Feb.  1883.  i  tempted,  as  he  informs  us,  the  taslv  of  presenting 

The  aim  of  the  author  has  been  to  present  to  his  in  a  condensed  form  the  results  of  the  latest  ob- 
readers  a  work  not  only  expounding  the  most  servation  and  experience.  A  careful  examination 
modern  conceptions  of  his  subject,  but  presenting  |  of  the  work  convinces  us  that  he  has  accomplished 
what  is  of  standard  value.  He  has  more  especially  !  his  task  with  painstaking  fidelity  and  with  a  cred- 
devoted  its  pages  to  the  treatment  of  disease,  and  :  itable  result. — Journal  of  Cutaneous  and  Venereal 
by  his  detailed  descriptions  of  therapeutic  meas-  Diseases,  June,  1883. 
ures  has  adapted  them  to  the  needs  of  the  physi-  1 


Physician  to  the  Department  for  Skin  Diseases, 
University  College  Hospital,  London. 


FOX,  T.,  M,J).,F,It,C,JP,,andFOX,T,C.,B.A,,3I.It,C,S,, 

Physician  for  Diseases  of  the  Skin  to  the 
Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Forraulse.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  very  handsome  12mo.  volume 
of  238  pages.     Cloth,  $1 .25.     Just  ready. 


The  third  edition  of  this  convenient  handbook 
calls  for  notice  owing  to  the  revision  and  expansion 
which  it  has  undergone.  Thearrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 


manual  to  lie  upon  the  table  for  instant  reference. 
Its  alphabetical  arrangement  is  suited  to  this  use, 
for  all  one  has  to  know  is  the  name  bf  the  disease, 
and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases    are  de- 


to  students  but  also  to  practitioners  who  require  a  i  scribed,  while  most  of  the  recent  additions  to 
compendious  summary  of  the  present  state  of  i  dermal  therapeutics  find  mention,  and  the  formu- 
dermatology. — British  Medical  Journal,  July  2, 1883.    lary  at  the  end  of  the  book  has  been  considerably 

We  cordially  recommend  Fox's  Epitome'to  those    augmented. — The  Medical  News,  December,  1883. 
whose  time  is  limited  and  who  wish   a  handy  | 

MOMJRIS,  MALCOLM,  M,  D., 

Joint  Lecturer  on  Dermatology  at  St.  Mary's  Hospital  Medical  School,  London. 
Skin  Diseases ;  Including  their  Definitions,  Symptoms,  Diagnosis,  Prognosis,  Mor- 
bid Anatomy  and  Treatment.     A  Manual  for  Students  and  Practitioners.     In  one  12mo. 
volume  of  316  pages,  with  illustrations.     Cloth,  $1.75. 

for  clearness  of  expression  and  methodical  ar- 
rangement is  better  adapted  to  promote  a  rational 
conception  of  dermatology — a  branch  confessedly 
difficult  and  perplexing  to  the  beginner. — St.  Louu 
Courier  of  Medicine,  April,  1880. 
The  writer  has  certainly  given  in  a  small  compass 


To  physieianswho  wouldlike  to  know  something 
about  skin  diseases,  so  that  when  a  patient  pre- 
sents himself  for  relief  they  can  make  a  correct 
diagnosis  and  prescribe  a  rational  treatment,  we 
unhesitatingly  recommend  this  little  book  of^  Dr. 
Morris.  The  affections  of  the  skin  are  described 
in  a  terse,  lucid  manner,  and  their  several  charac- 
teristics so  plainly  set  forth  that  diagnosis  will  be 
easy.  The  treatment  in  each  case  is  such  as  the 
experience  of  tiie  most  eminent  dermatologists  ad- 
vises.— Cincinnati  Medical  News,  April,  1880. 

This  is  emphatically  a  learner's  book;  for  we 
can  safely  say,  that  in  the  whole  range  of  medical 
literature  there  is  no  book  of  a  like  scope  which 


a  large  amount  of  well-compiled  information,  and 
his  little  book  compares  favorably  with  any  other 
which  has  emanated  from  England,  while  in  many 
points  he  has  emancipated  himself  from  the  stub- 
bornly adhered  to  errors  of  others  of  his  country- 
men. There  is  oertainly  excellent  material  in  the 
book  which  will  well  repay  perusal. — Boston  Med, 
and  Surg.  Journ.,  March,  1880. 


WILSOJV,  ERASMUS,  F,  B,  S, 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 
In  one  handsome  small  octavo  volume  of  535  pages.     Cloth,  $3.50. 

HILLIEIt,  THOMAS,  M,  D,, 

Physician  to  the  Skin  Department  of  University  College,  London. 
Handbook  of  Skin  Diseases ;  for  Students  and  Practitioners.     Second  Ameri- 
can edition.    In  one  12mo.  volume  of  353  pages,  withjplates.     Cloth,  $2.25. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Dis.  of  Women.         27 


^JV"  AMERICAN  SYSTEM  OF  GYNECOLOGY, 

A  System  of  Gynaecology,  in  Treatises  by  Various  Authox'S.   In  two 

handsome  octavo  volumes  ,  riclily  illustrated.     In  active  preparation. 

LIST  OF  CONTRIBUTORS. 

FORDYCE  BARKER,  M.  D.,  CHARLES  CARROLL  LEE,  M.  D., 

ROBERT  BATTEY,  M.  D.,  WILLIAM  T.  LUSK,  M.  D., 

SAMUEL  C.  BUSEY,  M.  D.,  MATTHEW  D.  MANN,  M.  D., 

HENRY  F.  CAMPBELL,  M.  D.,  ROBERT  B.  MAURY,  M.  D., 

BENJAMIN  F.  DAWSON,  M.  D.,  C.  D.  PALMER,  M.  D., 

WILLIAM  GOODELL,  M.  D.,  WILLIAM  M.  POLK,  M.  D., 

HENRY  F.  GARRIGUES,  M.  D.,  THAPDEUS  A.  REAMY,  M.  D., 

SAMUEL  W.  GROSS,  M.  D.,  A.  D.  ROCKWELL,  M.  D., 

JAMES  B.  HUNTER,  M.  D.,  ALBERT  H.  SMITH,  M.  D., 

WILLIAM  T.  HOWARD,  M.  D.,  R.  STANSBURY  SUTTON,  A.  M.,  M.  D., 

A.  REEVES  JACKSON,  M.  D.,  T.  GAILLARD  THOMAS,  M.  D., 

EDWARD  W.  JENKS,  M.  D.,  CHARLES  S.  WARD,  M.  D.. 
WILLIAM  H.  WELCH,  M.  D. 


THOMAS,  T.  GAILLAUD,  M.  D., 

Professor  of  Diseases  of  Women  in  the  College  of  Physicians  ayid  Surgeons,  iV.  1'. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.     Cloth,  $5.00 ;  leather,  $6.00 ;  very  handsome  half  Kussia,  raised  bands,  $6.50. 

The  words  which  follow  "  fifth  edition"  are  in  I  vious  one.  As  a  book  of  reference  for  the  busy 
this  ease  no  mere  formal  announcement.  The  i  practitioner  it  is  unequalled. — Boston  Medical  arid 
alterationsandadditions  which  have  been  made  are  ]  Surgical  Journal,  April  7, 1880. 

both  numerous  and  important.  The  attraction  ■  It  has  been  enlarged  and  carefully  revised.  It  is 
and  the  permanent  character  of  this  book  lie  in  a  condensed  encycTopsBdia  of  gyntecological  medi- 
the  clearness  and  truth  of  the  clinical  descriptions  1  cine.  The  style  of  arrangement,  the  masterly 
of  diseases ;  the  fertility  of  the  author  in  thera-  1  manner  in  which  each  subject  is  treated,  and  the 
peutic  resources  and  tlie  fulness  with  which  tlie  j  honest  convictions  derived  from  probably  the 
details  of  treatment  are  described;  the  definite  largest  clinical  experience  in  that  specialty  of  any 
character  of  the  teaching;  and  last,  but  not  least,  \  in  this  country,  all  serve  to  commend  it  in  the 
the  evident  candor  which  pervades  it.  We  would  ;  highest  terms  to  the  practitioner. — Nashville  Jour. 
also  particularize  the  fulness  with  which  the  his-  ;  of  Med.  and  Surg.,  Jun.  1881. 

tory  of  the  subject  is  gone  into,  which  makes  the  j  That  the  previous  editions  of  the  treatise  of  Dr. 
book  additionally  interesting  and  gives  it  value  as  i  Thomas  were  thought  worthy  of  translation  into 
a  work  of  reference.— ionrfou  Medical  Times  and  German,  French,  Italian  and  Spanish,  is  enough 
Oazette,  July  30, 1881.  to  give  it  the  stamp  of  genuine  merit.    At  home  it 

The  determination  of  the  author  to  keep  his  i  has  made  its  way  into  the  library  of  every  obstet- 
book  foremost  in  the  rank  of  works  on  gynsecology  !  rician  and  gynsecologist  as  a  safe  guide  to  practice. 
Is  most  gratifying.  Recognizing  the  fact  that  this  '  No  small  number  of  additions  have  been  made  to 
can  only  be  accomplished  by  frequent  and  thor-  I  the  present  edition  to  make  it  correspond  to  re- 
ougn  revision,  he  has  spared  "no  pains  to  make  the  ;  cent  improvements  in  treatment. — Pacific  Medical 
present  edition  more  desirable  even  than  the  pre-  i  and  Surgical  Journal,  Jan.  1881. 

EDIS,  ABTHTJB  W,,  M.  lb,,  Land.,  F.R.  CF,,  M.It,  C,S,, 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 

The  Diseases  of  Women.  Including  their  Pathologj',  Causation,  Symptoms, 
Diagnosis  and  Treatment.  A  Manual  for  Students  and  Practitioners.  In  one  handsome 
octavo  volume  of  576  pages,  with  148  illustrations.     Cloth,  $3.00;  leather,  $4.00. 

The  greatest  pains  have  been  taken  with  the 
sections  relating  to  treatment.  A  liberal  selection 
of  remedies  is  given  for  each  morbid  condition, 
the  strength,  mode  of  application  and  other  details 
being  fully  explained.    The  descriptions  of  gynse- 


It  is  a  pleasure  to  read  a  book  so  thoroughly 
good  as  this  one.  The  special  qualities  which  are 
conspicuous  are  thoroughness  in  covering  the 
whole  ground,  clearness  of  description  and  con- 
ciseness of  statement.    Another  marked  feature  of 


the  book  is  the  attention  paid  to  the  details  of  [  cological  manipulations  and  operations  are  full, 
many  minor  surgical  operations  and  procedures,  i  clear  and  practical.  Mitch  care  has  also  been  be- 
as,  for  instance,  the  use  of  tents,  application  of  I  stowed  on  the  parts  of  the  book  which  deal  with 


diagnosis — we  note  especially  the  pages  dealing 
with  the  differentiation,  one  from  another,  of  the 
different  kinds  of  abdominal  tumors.  The  prac- 
titioner will  therefore  find  in  this  book  the  kind 
of  knowledge  he  most  needs  in  his  daily  work,  and 
he  will  be  pleased  with  the  clearness  and  fulness 
of  the  information  there  given. — The  Practitioner, 
Feb.  1882. 


leeches,  and  use  of  hot  water  injections.  These 
are  among  the  more  common  methods  of  treat- 
ment, and  yet  very  little  is  said  about  them  in 
many  of  the  text-books.  The  book  is  one  to  be 
warmly  recommended  especially  to  students  and 
general  practitioners,  who  need  a  concise  but  com- 
plete resume  of  the  whole  subject.  Specialists,  too, 
will  find  many  useful  hints  in  its  pages. — Boston 
Med.  and  Surg.  Journ.,  March  2, 1882. 

BARNES,  ROBERT,  M.  D.,  F.  R,  C.  F,, 

Obstetric  Physician  to  St.  Thomas''  Hospital,  London,  etc. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseases  of  Women. 
In  one  handsome  octavo  volume,  with  numerous  illustrations.     New  edition.    Preparing. 

CHAnWICK,  JAMES  R.,  A.  M.,  M,  D. 

A  Manual  of  the  Diseases  Peculiar  to  Women.    In  one  handsome  royal 
12mo.  volume,  with  illustrations.     Preparing. 

WEST,  CHARLESiW,lD, 

Lectures  on  the  Diseases  of  Women.    Third  American  from  the  third  Lon- 
don edition.     In  one  octavo  volume  of  543  pages.     Cloth,  $3.75 ;  leather,  $4.75. 


28     Henry  C.  Lea's  Son  &  Co.'s  Publications — Dis.  of  Womeu,  Midwfy. 
EMMET,  TH03IAS  ADDIS,  M,  D,,  LL,  D,, 

Surgeon  to  the  Wommi's  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  ^ledicine.  Second  edition.  Thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  ot  879  pages,  with  133  illustrations.  Cloth,  $5.00 ;  leather,  $6.00 ; 
very  handsome  half  Kussia,  $6.50. 

No  gynsecological  treatise  has  appeared  which  ceived  more  attention  than  in  America.  It  is, 
contains  an  equal  amount  of  original  and  useful  tlien,  witii  a  feeling  of  pleasure  that  we  welcome  a 
matter;  nor  does  the  medical  and  surgical  history  work  on  diseases  of  women  from  so  eminent  a 
of  America  include  a  book  more  novel  and  useful,  gyniecologist  as  Dr.  Emmet.  The  work  is  essen- 
The  tabular  and  statistical  information  which  it  :  tially  clinical,  and  leaves  a  strong  impress  of  the 
contains  is  marvellous,  both  in  quantity  and  accu-  1  autlior's  individuality.  To  criticise,  with  the  care 
racy,  and  cannot  be  otherwise  than  invaluable  to  I  it  merits,  the  book  throughout,  would  demand  far 
future  investigators.  It  is  a  work  which  demands  more  space  than  is  at  our  command.  In  parting, 
not  careless  reading  but  profound  study.  Its  value  we  can  say  that  the  work  teems  with  original 
as  a  contribution  to  gyntecology  is,  perhaps,  ideas,  fresh  and  valuable  methods  of  practice,  and 
greater  than  that  of  all  previous  literature  on  the  i  is  written  in  a  clear  and  elegant  style,  worthy  of 
subject  combined. — Chicago  Medical  Gazette,  April  I  theliterary  reputation  of  the  country  of  Longfellow 
6,1880.  '  j  and  Oliver  Wendell  Holmes. — British  Med.  journal. 

In  no  country  of  the  world  has  gynaecology  re-  i  Feb.  21, 1880. 


nUWCAJy,  J,  MATTHEWS,  3I.I).,  LL.  D.,  F.  B.  S,  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.    In  one  handsome  octavo  volume  of  175  pages.    Cloth,  $1.50. 

They  are  in  every  way  worthy  of  their  author;  \  stamp  of  individuality  that,  if  widely  read,  as  they 

indeed,  we  look  upon  them  as  among  the  most  certainly  deserve  to  be,  they  cannot  fail  to  exert  a 

valuable  of  his  contributions.    They  are  all  upon  wholesome  restraint  upon  the  undue  eagerness 

matters  of  great  interest  to  the  general  practitioner,  with  which  many  young  physicians  seem   bent 

Some  of  them  deal  with  subjects  that  are  not,  as  a  upon  following  the  wild  teachings  which  so  infest 

rule,  adequately  handled  in  the  text^books;  others  the  gynsecology  of  the  present  day. — N.  Y.  Medical 

of  them,  while  bearing  upon  topics  that  are  usually  Journal,  Marcii,  1880. 
treated  of  at  length  in  such  works,  yet  bear  such  a 


GTISSEROW,  A,, 

Professor  of  Midwifery  and  the  Diseases  of  Children  at  the  University  of  Berlin. 

A  Practical  Treatise  on  Uterine  Tumors.  Specially  revised  by  the  Author, 
and  translated  with  notes  and  additions  by  Edmund  C.  "NVendt,  M.  D.,  Pathologist  to  the 
St.  Francis  Hospital,  N.  Y.,  etc.,  and  revised  by  Nathan  Bozeman,  M.  D.,  Surgeon  to  the 
Woman's  Hospital  of  the  State  of  !New  York.  In  one  handsome  octavo  volume,  with  about 
40  illustrations.     Preparing. 


SOnGE,  JEEVGSL.,  M.  J>., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.     In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.     Cloth,  $4.50. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  v.'ood- 
cuts.  In  one  large  quarto  volume  of  542  double-columned  pages.  Strongly  bound  in 
cloth,  $14.00. 

*  ^*  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by 
mail,  on  receipt  of  six  cents  in  postage  stamps. 


TAJRJ^IEB,    S.,    and    CSAWTREUIL,    G. 

A   Treatise   on  the  Art  of  Obstetrics.      Translated  from  the  French.     In 
two  large  octavo  volumes,  richly  illustrated. 


KAMSBOTHA3I,  FRANCIS  JS.,  M.  D, 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery; 
In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  tlioroughly  revised 
by  the  Author.  With  additions  by  W.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  Medical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.     Strongly  bound  in  leather,  with  raised  bands,  $7. 


ASHWELL'3  PRACTICAL  TREATISE  ON  THE  1  AND  OTHER  DISEASES  PECULIAR  TO  WO- 
DISEASES  PECULIAR  TO  WOMEN.  Third  |  MEN.  In  one  8vo.  vol.  of  404  pages.  Cloth,  S2.50. 
American  from  the  third  and  revised  London  i  MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth.  83.50.     |      mENT  OF  CHILDBED  FEVER.    In  one  8vo. 

CHURCHILL  ON   THE   PUERPERAL  FEVER  i      volume  of  346  pages.    Cloth,  §2.00. 


Henry  C.  Lea's  Son  &  Co.'s  Publications — Midwifery.  29 

rLAYFAIM,  W.  S.,  31,  !>.,  F.  JR.  C,  JP., 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  Third  American 
edition,  revised  by  the  Author.  Edited,  with  additions,  by  Robert  P.  Harris,  M.  D. 
In  one  handsome  octavo  volume  of  659  pages,  with  183  illustrations.  Cloth,  $4;  leather, 
$5;  half  Russia,  $5.50. 

The  medical  profession  has  now  the  opportunity!  all  details  not  necessary  for  a  full  understanding 
of  adding  to  their  stock  of  standard  medical  works  of  the  subject  are  omitted.— Cincinnati  Meaical 
one  of  tiie  best  volumes  on  midwifery  ever  pub-    Netvs,  Jan.,  1880. 

lished.  The  subject  is  taken  up  with  a  master,  it  certainly  is  an  admirable  exposition  of  the 
hand.  The  part  devoted  to  labor  in  all  its  various  j  science  and  practice  of  midwifery.  Of  course  the 
presentations,  the  management  and  results,  is  ad-  j  additions  made  by  the  American  editor,  Dr.  R.  P. 


mirabiy  arranged,  and  trie  views  entertained  will 
be  found  essentially  modern,  and  the  opinions  ex- 
pressed trustworthy.  The  work  abounds  with 
plates,  illustrating  Various  obstetrical  positions ; 
they  are  admirably  wrought,  and  afford  great 
assistance  to  the  student.— 1\'.  0.  Medical  and  Sur- 


Harris,  who  never  utters  an  idle  word,  and  whose 
studious  researches  in  some  special  departments 
of  obstetrics  are  so  well  known  to  the  profession, 
are  of  great  value. —  The  American  Practitioner, 
April,  1880. 
The  third  edition — so  soon  following  the  second — 


gica!  Jaurnal,  March,  1880.  j  shows  that  the  good  qualities  of  the  book  have  been 

If  inquired  of  by  a  medical  student  what  work  [  recognized  by  the  profession.  The  second  Ameri- 
on  obstetrics  we  should  recommend  for  him,  par  i  can  has  beeuexhausted  before  the  second  English 
exeelUnce,  we  would  undoubtedly  advise  him  to{  edition,  and  this  is  therefore  especially  prepared 
choose  Playfair's.  It  is  of  convenient  size,  but ;  and  revised  by  the  author  for  this  country  ;  a  fact 
what  is  of  chief  importance,  its  treatment  of  the ;  which  ought  to  be  satisfactory  as  to  the  profession 
various  subjects  is  concise  and  plain.  While  the  [  here  being  furnished  with  the  latest  work  upon  all 
discussions  and  descriptions  are  sufficiently  elabo- 1  subjects  pertaining  to  obstetrics. — Am.  JourncUof 
rate  to  render  a  very  intelligible  idea  of  them,  yetj  Med.  Sciences,  April,  1880. 


KING,  A.  F,  A,,  M,  D., 

Professor  of  Obstetrics  and  Diseases  of  WoTnen  tn  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     New  edition.     In  one  very  handsome  12mo.  volume 
of  331  pages,  with  59  illustrations.     Cloth,  $2.00.     Just  ready. 
A  notice  of  the  previous  edition  is  appended. 

lent  obstetric  dictionary,  and  well  suited  to  the  stu- 


Though  the  book  appears  small  externally,  it 
contains  as  complete  a  consideration  of  obstetric 
subjects  as  many  larger  volumes,  and  this  is 
chiefly  owing  to  a  directness  of  expression,  and  an 


dent,  it  is  also  of  value  to  the  genei-al  practitioner, 
who  often  desires  to  find  a  rtsume  of  information 
upon  a  given  subject.    It  will  be  of  further  value 


avoidance  of  repetition  and  of  waste  of  words.  ;  to  the  latter,  as,  in  our  opinion,  the  author  holds 
The  author  endeavors  to  place  theories,  causes  of  \  most  sensible  views  on  practical  matters.  The 
disease  and  methods  of  treatment  in  that  order  I  book  is  admirably  arranged  for  reference,  being 
which,  by  weight  of  authority,  they  merit.  His  well  paragraphed,  with  suitable  sub-divisions,  ana 
excellent  judgment  has  availed  him  well  in  this  well  indexea. — American  Journal  of  Obstetrics,  Xng. 
effort.    While,  in  one  sense,  the  book  is  an  excel- 1  1882. 


FAJRVIW,  THEOFSILUS,  M,  ID,,  LL,  2>., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  and  Children  in  the  Jefferson  Medical  CoUege. 
A  Treatise  on  Midwifery.     In  one  very  handsome  octavo  volume  of  about  550 
pages,  with  numerous  illustrations.     In  press. 

BARNES,  ROBERT,  M,  D,,   and   FAWCOURT,  M,  D., 

Phys.  to  the  General  Lying-in  IIosp.,  Land.  Obstetric  Phys.  to  St.  Thomas'  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.     In  two  handsome  octavo  volumes,  profusely  illustrated.    In  press. 

BARWES,  FAWCOTJRT,  M,  !>., 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London. 

A  Manual  of  Midwifery  for  Midwives  and  Medical  Students.  In  one 
royal  12mo.  volume  of  197  pages,  with  50  illustrations.     Cloth,  $1.25. 

FARRY,  JOHN  S.,  M.  I),, 

Obstetrician  to  the  Philadelphia  Hospital,  Vice-FYesident  of  the  Obstet  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy:  Its  Clinical  History,   Diagnosis,   Prognosis  and 
Treatment.     In  one  handsome  octavo  volume  of  272  pages.     Cloth,  $2.50. 

TANNER,  TS03IAS  HAWKES,  31.  I>. 

On  the  Signs  and  Diseases  of  Pregnancy.  First  American  from  the  second 
English  edition.  In  one  handsome  octavo  volume  of  490  pages,  with  4  colored  plates  and 
16  wocKlcuts.     Cloth,  $4.25. 

WINCKEL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed. 

For  Students  and  Practitioners.  Translated,  witli  the  consent  of  the  Author,  from  the 
second  German  edition,  bv  James  Read  Chadwick,  M.  D.  In  one  octavo  volume  of  484 
pages.     Cloth,  $4.00. 


30      Henry  C.  Lea's  Son  &  Co.'s  Publications — Midwfy.,  Dis.  Cliildn. 


LBISHMAJN,  WILLIAM,  M.  !>., 

Setfius  Professor  of  Midwifery  in  the  UniversHy  of  Olasgoic,  etc, 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50 ;  very  handsome  half  Kussia,  raised  bands,  $6.00. 
The  author  is  broad  in  his  teachings,  and  dis-     preparation  of  the  present  edition  the  author  has 


cusses  briefly  the  comparative  anatomy  of  the  pel 
vis  and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  study  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plainand  pleasing.  It  is  sufficient  to  state  that  in 
this,  the  last  edition  of  this  well-known  work, every 
recent  advancement  in  this  field  has  been  brought 
forward. — Phpsician  and  Surgeon,  Jan.  1880. 

We  gladly  welcome  the  new  edition  of  this  ex- 
cellent text-book  of  midwifery.  The  former  edi- 
tions have  been  most  favorably  received  by  the 
profession  on  both  sides  of  the  Atlantic.    In  the 


ade  such  alterations  as  the  progress  of  obstetri- 
cal science  seems  to  require,  and  we  cannot  but 
admire  the  ability  with  which  the  ta.sk  has  been 
performed.  We  consider  it  an  admirable  text- 
book for  students  during  their  attendance  upon 
lectures,  and  have  great  pleasure  in  recommend- 
ing it.  As  an  exponent  of  the  midwiferv  of  the 
present  day  it  has  no  superior  in  the  Enghsh  lan- 
guage.— Canada  Lancet,  Jan.  1880. 

To  the  American  student  the  work  before  as 
must  prove  admirably  adapted.  Complete  in  all  its 
parts,  essentially  modern  in  its  teachmgs,  and  with 
demonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and  Surg.  Joum.,  March,  1880. 


SMITH,  J.  LEWIS,  M.  !>., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  T. 

A  Complete  Practical  Treatise  on  the  Diseases  of  Children.    Fifth 

edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  836  pages, 
with  illustrations.  Goth,  $4.50 ;  leather,  $5.50 ;  very  handsome  half  Russia,  raised  hands,  $6. 
This  is  one  of  Ihe  best  books  on  the  subject  with  \  tioners  on  such  questions  as  etiology,  pathology. 


which  we  have  met  and  one  that  has  given 
satisfaction  on  every  occasion  on  which  we  have 
consulted  it,  either  as  to  diagnosis  or  treatment. 
It  is  now  in  its  fifth  edition  and  in  its  present  form 
is  a  very  adequate  representation  of  the  subject  it 
treats  o"f  as  at  present  under.'^tood.  The  important 
subject  of  infant  hygiene  is  fully  dealt  with  in  the 
earlv  portion  of  the  Dook.  Tlie  great  bulk  of  the 
work  is  appropriately  devoted  to  the  diseases  of 
infancy  and  childhood.  We  would  recommend 
any  one  in  need  of  information  on  the  subject  to 
procure  the  work  and  form  his  own  opinion  on  it, 
which  we  venture  to  say  will  be  a  favorable  one. — 
jyublin  .Toumal  of  Medical  Scienrc,  March,  1883. 

There  is  no  book  published  on  the  subjects  of 
which  this  one  treats  that  is  its  eq_ual  in  value  to 
the  physician.  While  he  has  said  just  enough  to 
impart  the  information  desired  by  general  practi- 


prognosis,  etc.,  he  has  devoted  more  attention  to 
the  diagnosis  and  treatment  of  the  ailments  which 
he  so  accurately  describes  ;  and  such  information 
is  exactly  what  is  wanted  by  the  vast  majority  of 
'•  family  physicians."—  Va.  Med.  Monthly,  Feb.  1882. 
It  is  a  pleasure  to  peruse  such  a  work  as  the  one 
before  us,  and  as  reviewers  we  have  but  one  diflS- 
culty— there  is  but  little  to  find  fault  with.  The 
author  understands  what  he  writes  about  from  a 
practical  acquaintance  with  the  diseases  incident 
to  infancy  and  childhood,  and  also  thoroughly 
comprehends  their  pathology  and  therapeutics. 
The  work  is  full  of  original  aiid  practical  remarks 
which  will  be  particularly  acceptable  to  the  student 
and  young  physician;  biit  at  the  same  time  we  can 
with  great  sincerity  commend  it  to  the  notice  of 
the  profession  in  general. — Edinb.  Med.  JL,  May,  '82. 


In 


KEATING,  JOHNM,,  M,  I)., 

Lecturer  on  the  Diseases  of  Children  at  the  University  of  Pennsylvania,  etc. 

The  Mother's  Guide  in  the  Management  and  Feeding  of  Infants 

one  handsome  12mo.  volume  of  118  pages.     Cloth,  $1.00. 

Works  like  this  one  will  aid  the  physician  im-  I  the  employment  of  a  wet-nurse,  about  the  proper 
mensely,  for  it  saves  the  time  he  is  constantly  giv-  I  food  for  a  nursing  mother,  about  the  tonic  effects 
ing  his  patients  in  instructing  them  on  the  sub-  i  of  a  bath,  about  the  perambulator  rerstts  the  nurses' 
jects  here  dwelt  upon  so  thoroughly  and  prac-  •  arms,  and  on  many  other  subjects  concerning 
tically.    Dr.  Keating  has  vvritten  a  practical  book.  I  whien  the  critic  might  say,  "surely  this  is  obvi- 


has  carefully  avoided  unnecessary  repetition,  and 
successfully  instructed  the  mother  in  such  details 
of  the  treatment  of  her  child  as  devolve  upon  her. 
He  has  studiously  omitted  giving  prescriptions. 


ous,"  but  which  experience  teaches  us  are  exactly 
the  things  needed  to  be  insisted  upon,  with  the  ricn 
as  well  as  the  poor. — London  Lancet,  January,  28 1882. 
A  book  small  in  size,  written  in  pleasant  style,  in 


and  instructs  the  mother  when  to  call  upon  the  !  language  which  can  be  readily  understood"^  by  any 


doctor,  as  his  duties  are  totally  distinct  from  hers.  ] 
— American  Journal  of  Obstetrics,  October,  1881. 

Dr.  Keating  has  kept  clear  of  the  common  fault 
of  works  of  this  sort,  viz.,  mixing  the  duties  of 
the  mother  with  those  proper  to  the  doctor.  There 
is  the  ring  of  common  sense  in  the  remarks  about 


mother,  and  eminently  practical  and  .'^afe;  in  fact 
a  book  for  which  we  have  been  waiting  a  long 
time,  and  which  we  can  most  heartily  recommend 
to  mothers  as  the  book  on  this  subject. — New  York 
Medical  Journal  and  Obstetrical  Pevietc,  Feb.  1882. 


WEST,  CSAMLES,  M,  D,, 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc 

Lectures  on  the  Diseases  of  Infancy  and  Childhood.  P^ifth  American 
from  the  sixth  revised  and  enlargeti  English  edition.  In  one  large  and  handsome  octavo 
volume  of  686  pages.     Cloth,  $4.50 ;  leather,  $5.50. 


By  the  Same  Author. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood. 
12mo.  volume  of  127  pages.    Cloth,  $1.00. 


In  one  small 


CX)NDIE'S   PRACTICAL    TREATISE   ON    THE 
DISEASES  OF  CHILDREN.    Sixth  edition,  re- 


vised and  augmented.    In'one  octavo  Tolame  of 
779  pages.    Cloth,  $5.25 ;  leather,  $6.26. 


Henr?  C.  Lea's  Son  &  Co.'s  Publications — ^Med.  Juris.,  Miscel.     31 


TinY,  CHARLES  MEYMOTT,  M.  B.,  F.  C,  S., 

Professor  of  Chemistry  and  oj  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  ete. 
liOgal  Medicine.     Volume  II.      Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Rape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.     Making  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.     Cloth,  $6.00;  leather,  $7.00.     Just  ready. 

Volume  I.     Containing   664    imperial   octavo   pages,  with  two  beautiful   colored 
plates.     Cloth,  $6.00 ;  leather,  $7.00.     Recently  issued. 
He  whose  inclinations  or  necessities  lead  him  to  I  The  fact  that  the  very  numerous  illustrative  cases 


assume  the  functions  of  a  medical  jurist  wants  a 
book  encyclopeedic  in  character,  in  which  he  may 
be  reasonably  sure  of  finding  medico-legal  topics 
discussed  wih  judicial  fairness,  with  sufficient 
completeness,  and  with  due  attention  to  the  most 
recent  advances  in  medical  science.  Mr.  Tidy's 
work  bids  fair  to  meet  this  need  satisfactorily. 


are  drawn  from  many  sources,  and  are  not  limited, 
as  in  Casper's  Handbook,  to  the  author's  own  ex- 
perience, and  the  additional  fact  that  they  are 
brought  down  to  a  very  recent  date,  give  them, 
for  purposes  of  reference,  a  very  obvious  value. — 
Boston  Medical  and  Surgical  Journal,  Feb.  8,  1883. 


TAYZOJR,  ALFBEJD  S.,  M.  D., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Ouy's  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revise<l  and  rewritten.  Edited  by  John  J.  Reese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00;  leather,  $6.00;  half 
Russia,  raised  bands,  $6.50. 

The  American  editions  of  this  standard  manual  !  only  have  to  seek  for  laudatory  terms. — American 
have  for  a  long  time  laid  claim  to  the  attention  of  I  Journal  of  the  Medical  Sciences,  Jan.  1881. 


the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which  he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  facile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the  author  and  the  book  have  made  a  mark  too 
deep  to  be  affected  by  criticism,  whether  it  be 
censure  or  praise.  In  this  case,  however,  we  should 


This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  tliirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  is 
simply  indispensable  to  every  physician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26,  1881. 


By  the  Same  Author. 
The  Principles  and  Practice  of  Medical  Jurisprudence.    Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations.     Cloth,  $10 ; 
leather,  $12.     Just  ready. 

The  revision  of  the  third  edition  of  this  standard  work  has  been  most  happily  con- 
fided to  a  gentleman  who  was  during  fourteen  years  the  colleague  of  the  author,  and  who 
therefore  is  thoroughly  conversant  with  the  methods  of  thought  which  have  everywhere 
gained  for  the  book  an  exalted  position  as  a  work  of  reference.  In  its  present  form  the 
work  is  the  most  complete  exposition  of  Forensic  Medicine  in  the  English  language. 

Taylor's  Treatise  at  the  hands  of  Dr.  Stevenson 
has  undergone  a  diminution  of  bulk  with  an  in- 
crease of  mass.    This  edition  only  asserts  with 


stronger  reason  the  allowed  claims  of  the  late  Dr. 
Taylor's  work  to  the  first  position  among  English 


books  of  its  class.  Including  within  its  purview, 
as  the  subject  does,  something  from  every  divi- 
sion of  medical  science,  this  exhaustive  treatise 
will  ever  remain  an  invaluable  collection  of  data. 
— New  York  Medical  Journal,  Dec.  1, 1883. 


By  the  Same  Author. 
Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.    Third 
American,  from  the  third  and  revised  English  edition.     In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 


LEA,  HENMY  C, 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  edition.  In  one 
handsome  royal  12mo.  volume  of  552  pages.     Cloth,  $2.50. 


This  valuable  work  is  in  reality  a  history  of  civ- 
ilization as  interpreted  by  the  progress  of  jurispru- 
denoe.  .  .  In  "Superstition  and  Force"  we  have  a 
philosophic  survey  of  the  long  period  intervening 
between  primitive  barbarity  and  civilized  enlight- 
•enment.    There  is  not  a  chapter  in  the  work  that 


should  not  be  most  carefully  studied ;  and  however 
well  versed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Westmimter  Review,  Jan.  1880. 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power — Ben- 


efit of  Clergy — Excommunication 

octavo  volume  of  605  pages.     Cloth,  $2.50. 

Tho  author  is  pre-eminently  a  scholar.  He  takes 
np  every  topic  allied  with  the  leading  theme,  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary.  In  no 
other  single  volume  is  the  development  of  the 


New  edition.     In  one  very  handsome  royal 

Just  ready.  ' 

primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
conflicting  sources.  The  fifty  pages  on  the  growth 
of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness and  freedom  from  prejudice. — Boston 
Traveller,  May  3, 1883. 


32    Henry  C.  Lea's  Son  &  Co.'s  Medical  and  Surgical  Publications. 
INDEX  TO  CATALOGUE. 


American  Journal  of  the  Medical  Sciences 

American  System  of  Gynaecology    . 

Allen's  Anatomy 
"♦Ashliurst's  Surgery     . 

Ashwell  on  Diseases  of  Women 
^tttleld's  Chemistry      . 

Barlow's  Practice  of  Medicine 

Barnes'  Midwifery 

♦Barnes  on  Diseases  of  Women 

Barnes'  System  of  Obstetric  Medicine 

Bartholow  on  Electricity 

Basham  on  Renal  Diseases    . 

Bell's  Comparative  Physiology  and  Anatomy 

Bellamy's  Operative  Surgery 

Bellamy's  Surgical  Anatomy 

Blandford  on  Insanity 

Bloxam's  Chemistry     . 

Bowman's  Privctical  Chemistry 

*Bristowe's  Practice  of  Medicme 

Browne  on  the  Ophthalmoscope 

Browne  on  the  Tnroat 

Bruce's  Materia  Medica  and  Therapeutics 

Brunton's  Materia  Medica  and  Therapeutics 

♦Bryant's  Practice  of  Surgery 

♦Bumstead  on  Venereal  Diseases    . 

•Burnett  on  the  Ear      .... 

Carpenter  on  the  Use  and  Abuse  of  Alcohol 
-♦Carpenter's  Human  Physiology    . 

Carter  on  the  Eye  .... 

Centurj'  of  American  Medicme 

Chadwick  on  Diseases  of  Women    . 

Chambers  on  Diet  and  Regimen      . 

Churchill  on  Puerperal  Fever 

Clarke  and  Lockwood's  Dissectors'  Manual 

Classen's  Quantitative  Analysis 

Cleland's  Dissector        .... 

Clouston  on  Insanity     .... 

Clowes'  Practical  Chemistry 

Coats'  Pathology 

Coleman's  Dental  Surgery     . 

Condie  on  Diseases  of  Children 

Cooper's  Lectures  on  Surgery 

♦Cornil  and  Ranvier's  Pathological  Histol 

Cornil  on  Syphilis 

CuUerier's  Atlas  of  Venereal  Diseases 

♦Dalton's  Human  Physiology 

Daltou's  Topographical  Anatomy  of  the  Brain 

Davis'  Clinical  Lectures 

Druitt's  Modern  Surgery 

Dujardin-Beaumetz's  Dict'y  of  Therapeutics 

Duncan  on  Diseases  of  Women 
r*Dunglison's  Medical  Dictionary    . 

Edis  on  Diseases  of  Women   . 

Ellis'  Demonstrations  of  Anatomy 

♦Emmet's  Gynsecolog%' 

♦Erichsen's  Svstem  ot  Surgerj- 

Esmarch's  Early  Aid  In  Injuries  and  Accld'ts 

Farquharson's  "Therapeutics  and  Mat.  Med. 

Fenwick's  Medical  Diagnosis 

Finlayson's  Clinical  Diagnosis 

Flint  on  Auscultation  and  Percussion 

Flint  on  Phthisis  .  ... 

Flint  on  Physical  Exploration  of  the  Lungs 

Flint  on  Respiratory  Organs 

Flint  on  the  Heart         .  .  .  .      . 

♦Flint's  Clinical  Medicine 

Flint's  Essays      ....  * 

Flint's  Practice  of  Medicine 

Foster's  Physiology       .  .  .  . 

♦Fothergilrs  Handbook  of  Treatment     . 

Fownes'  Elementary  Chemistry     . 
rf'ox  on  Diseases  of  the  Skin  . 

Fuller  on  the  Lungs  and  Air  Passages     . 

Galloway's  Analysis     .... 

Gibuey's  Orthopsedic  Surgery 

Gibson's  Surgery  .  .      ^    •      , ,  • 

Gluge's  Pathological  Histology,  by  Leidy 
■  ♦Grav's  Anatomy  ..... 

Greene's  Medical  Chemistry  . 

Green's  Pathology  and  Morbid  Anatomy 

Griffith's  Universal  Formulary 

Gross  on  Foreign  Bodies  in  Air- 
Gross  on  Impotence  and  Sterility 

Gross  on  Urinary  Organs 
■.♦Gross' System  of  Surgery     . 

Gusserow  on  Uterine  Tumors 

Gj-necological  Transactions  . 

Habershon  on  the  Abdomen 

♦Hamilton  on  Fractures  and  Dislocations 

Hamilton  on  Nervous  Diseases 

Hartshorne's  Anatomy  and  Physiology  . 

Hartshorne's  Conspectus  of  the  Med.  Sciences 

Hartshorne's  Essentials  of  Medicine 

Hermann's  Experimental  Pharmacology 

Hill  on  Syphilis  ..... 

HUUer'8  Handbook  of  Skin  Diseases 


2  I  Hohlyn's  Medical  Dictionary 

27  I  Hodge  on  Women  .... 
6  I  Hodge's  Obstetrics         .... 

20  I  Hoffmann  and  Power's  Chemical  Analysis 

28  Holden's  Landmarks    .... 
9  I  Holland's  Medical  Notes  and  Reflections 

17  *Holmes'  System  of  Surgery 

29  i  Horner's  Anatomy  and  Histology 

27  I  Hudson  on  Fever  .... 

^^lyde  on  the  Diseases  of  the  Skin    . 
Vr  Jones  (C.  Handlield)  on  Nervous  Disorders 
'24    Keating  on  Infants       .... 
King's  Manual  of  Obstetrics  . 
5, 20    Klein's  Histology  .... 

5  La  Roche  on  Pneumonia,  Malaria,  etc.     . 
19    La  Roche  on  Yellow  Fever    . 

9    Laurence  and  Moon's  Ophthalmic  Surgery 
Lawson  on  the  Eye,  Orbit  and  Eyelid 

14  Dea's  Studies  in  Church  History 

23  Lea's  Supei"stitioii  and  Force 

18  Lee  on  Syphilis    ..... 
12    Lehmanh's  Chemical  Physiology    . 

12  *Leishman's  Midwifery 

21  Ludlow's  Manual  of  Examinations 
Lvons  on  Fever  ..... 

24  Maisch's  Organic  Materia  Medica  . 
8    Medical  News      ..... 

Meigs  on  Childbed  Fever 
2.3    Miller's  Practice  of  Surgery  . 

15  Miller's  Principles  of  Surgery 

27  Mitchell's  Nervous  Diseases  of  Women  . 
17    Morris  on  Skin  Diseases 

28  Neill  and  Smith's  Compendium  of  Med.  Scl. 

6  Netlleship  on  Diseases  of  the  Eye  . 
10    *Parrish's  Practical  Pharmacy 

5    Parry  on  Extra-Uterine  Pregnancy 

19  Parvin's  Midwifery       .... 
10    Pavy  on  Digestion  and  its  Disorders 

13  Pepper's  Surgical  Pathology 
24    Pirrie's  System  of  Surgery 

^i"Playfair  on  Nerve  Prostration  and  Hysteria 


21^Playfair's  Midwiferv 

*r  F  -         ■  -    ■ 


Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Physiology  . 

Ralfe's  Clinical  Cliemistry 

Ramsbotham  on  Parturition 

Rerasen's  Theoretical  Chemistry    . 

*Reynolds' System  of  Medicine 

Ricliardson's'Preventive  Medicine 

Roberts  on  Urinary  Diseases 

Roberts'  Principles  and  Practice  of  Surgery 

Robertson's  Physical  Physiology    . 

Rod  well's  Dictionarj- of  Science 

Sargent's  Minor  and  Military  Surgery     . 

Sciiiifer's  Histology       .... 

Seller  on  the  Throat,  Nose  and  Naso-Pharynx 

Skey's  Operative  Surgery 

Slade  on  Diphtheria      .... 

Smith  (Edward)  on  Consumption  . 

Smith  (H.  II.)  and  Horner's  Anatomical  Atlaa 

*Smith  (J.  Lewis)  on  Children 

*Stille  &  Maisch's  National  Dispensatory 

*Stilli5's  Therapeutics  and  Materia.  Medica 

Stirason  on  Fractures   .... 

Stimson's  Operative  Surgery 

Stokes  on  Fever  ..... 

Students' Series  of  Manuals  . 

Sturges'  Clinical  Medicine     . 

Tanner  on  Signs  and  Diseases  of  Pregnancy 

Tanner's  Manual  of  Clinical  Medicine     . 

Tarnier  and  Chantreuil's  Obstetrics 

Taylor  on  Poisons         .... 

*Tavlor's  Medical  Jurisprudence    . 

Taylor's  Priii.  and  Prac.  of  Med.  Jurisprudence 

♦Thomas  on  Diseases  of  Women     . 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .... 

Todd  on  Acute  Diseases 

Treves'  Applied  Anatomy 

Tuke  on  the  Influence  of  Mind  on  the  Body 

Walslie  on  the  Heart    .... 

Watson's  Practice  of  Physic  . 

Watts'  Pliysical  and  Inorganic  Chemistry 

♦Wells  on  the  Eye         .... 

West  on  Diseases  of  Childhood 

West  on  Diseases  of  Women 

West  on  Nervous  Disorders  in  Childhood 

Williams  on  Consumption     . 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson's  Human  Anatomy   . 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wohler's  Organic  Chemistry 

Woodbury's  Practice  of  Medicine  . 

Woodhead's  I»ractical  Pathology    . 


Books  marked  *  are  also  bound  in  half  Eussia. 


HENRY   C.    LEA'S    SON    &    CO., 

Philadelphia. 


Return  thKter1a?to  fh^  ?J  90024-1388 


o^ 


51 


[JC  SOU'^ERN  REGIONAL  LIBRARY  FACILITY 


A     000  501  378    4 


"C  IRVINE  LIBRARY 


3  1970  00982  "5982 


^100 
c6UTc 
l88U 

Clouston.    ^^res  on  mental 
Clinical  -Let. 
a.iseases 


WMIOO 
C61+7C 
188U 
Clouston. 

Clinical  lectures  on  mental 
diseases 


UCI  CCM  LIBRARY 


